(Eolumbta  Httiurrflitg 
in  %  (Eity  of  Nrro  fork 

(JlnlUgr  of  ptjgairtana  mb  §>urgrnua 


Krfmnre   iOtbranj 


CLINICAL  LECTURES 

ON 

ENLARGEMENT  OF  THE  PROSTATE 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/clinicallecturesOOfrey 


Clinical  Xecturee 


ON 


ENLARGEMENT  OF  THE 
PROSTATE 

MUtb  a  description  of  tbe  Hutbor's  ©peration  of 
Uotal  Enucleation  of  tbe  ©roan 


BY 

P.  J.    FREYER,   M.A..   M.D.,    M.Cn. 

Surgeon  to  King  Edward  VII.  s  Hospital  for  Officers,  and  to  St.  Peter's  Hospital 
L\te  Examiner  in  Surgery  at  the  Durham  University 

LlEUT.-CoLONEL,    INDIAN    MkIMCAI.    SERVICE   (ReTD.) 


THIRD   EDITION 


NEW    YORK 
WILLIAM    WOOD    *    COMPANY 

MDCCCCV] 


YbOCo 


PREFACE   TO   THE    THIRD    EDITION 

The  second  edition  of  my  lectures  on  '  Stricture  of  the 
Urethra  and  Enlargement  of  the  Prostate '  has  been  out  of 
print  for  some  months.  I  had  not  intended  issuing  a  new 
edition  of  this  work  in  separate  form,  as,  at  the  invitation 
of  the  Publishers,  I  am  engaged  in  preparing  a  more  or  less 
comprehensive  work  on  '  The  Surgical  Diseases  of  the 
Urinary  Organs.'  Owing,  however,  to  professional  demands 
on  my  time,  this  work  cannot  appear  as  early  as  I  anticipated. 
In  the  meantime  I  find  that  there  is  a  somewhat  pressing 
demand  for  the  lectures  on  the  prostate.  I  have,  therefore, 
decided  on  issuing  forthwith  the  lectures  on  the  prostatic 
portion  of  the  work  in  separate  form.  Consequent  on  the 
introduction  of  my  operation  of  total  enucleation  of  the 
enlarged  prostate,  the  original  lectures,  which  were  delivered 
in  November,  1900,  at  the  Medical  Graduates'  College  and 
Polyclinic,  have  been  entirely  re-written  and  amplified. 

P.  J.  F. 

27,    J  1  ARI.I.N     S  I  I'll    I  , 

London,  W., 

September,  1906. 


CONTENTS 

LECTUKE  PAGE 

I.    ENLARGEMENT        OF        THE        PROSTATE:         ITS        NATURE, 

PATHOLOGY,    SYMPTOMS,    AND    DIAGNOSIS  -  -  I 

II.    GENERAL    TREATMENT    OF    ENLARGED     PROSTATE    AND    ITS 

COMPLICATIONS  -  -  -  -  1 6 

III.    THE    AUTHOR'S    OPERATION     OF     TOTAL     ENUCLEATION     OF 

THE    ENLARGED    PROSTATE    IN    ITS    CAPSULE  -  -         33 

IV.    I. — DEVELOPMENTS  OF  THE  AUTHOR'S  OPERATION  INVOLV- 
ING PARTIAL  OR   TOTAL   REMOVAL   OF  THE  PROSTATIC 
URETHRA  -  -  -  -  -  -  62 

II.  —  THE    AFTER-TREATMENT    OF    PROSTATECTOMY  -  7  2 

V.    THE    SCOPE    AND    LIMITS    OF    THE     OPERATION     OF   TOTAL 

ENUCLEATION    OF    THE    PROSTATE        -  -  8 1 

VI.    I. — TOTAL  ENUCLEATION   OF  THE   PROSTATE   IN   ADVANCED 

OLD    AGE  ------       109 

II. — ENUCLEATION  OF  THE  WHOLE  OR  REMAINING  POR- 
TIONS OF  THE  PROSTATE  IN  CASK.-  PREVIOUSLY 
SI   EJECTED   TO    OPERATION    BY    OTHER    METHODS  -       1 24 

VII.    RESULTS    OF   THE    OPERATION    OF  TOTAL  ENUCLEATION  OF 

THE    PROSTATE,    WITH    SOME    CONCLUDINt,    REMARKS       139 


LECTURE  I 

ENLARGEMENT  OF  THE  PROSTATE  :  ITS  NATURE, 
PATHOLOGY,   SYMPTOMS,  AND  DIAGNOSIS 

Gentlemen, 

To-day  I  propose  considering  with  you  that  con- 
dition commonly  called  '  hypertrophy  of  the  prostate,'  an 
enlargement  of  the  organ  incidental  to  declining  years,  and 
which  frequently  causes  obstruction  to  the  urinary  flow.  It 
is  sometimes  named  '  senile  '  enlargement,  a  not  particularly 
appropriate  description,  as  the  disease,  if  it  occur  at  all,  sets 
in  long  before  senility  in  the  general  acceptation  of  that  term 
supervenes,  and  one  that  men  who  have  scarcely  turned 
middle  life  sometimes  resent  as  offensive.  As  the  disease  is 
not  a  hypertrophy  as  generally  understood,  perhaps  the  most 
appropriate  description  would  be  enlargement  of  the  prostate 
of  declining  life  ;  but  for  brevity  we  will  refer  to  it  simply  as 
'  <  nlargement  of  the  prostate.' 

It  will  be  convenient  in  the  first  instance  to  briefly  recall 
some  of  the  characteristic  features  of  the  healthy  organ. 
The  prostate  is  a  glandular  body  which  surrounds  the  neck 
of  the  bladder  and  the  adjacent  inch  of  the  urethra.  In  the 
adult  it  is  the  size  and  shape  of  a  chestnut,  bring  about 
i !  inches  broad,  i  inch  long,  and  |  inch  deep.  Its  average 
weight  is  4.]  drachms.  The  base:  is  directed  backwards  and 
upwards  towards  the  bladder,  the  neck  of  which  it  embra- 
and  the  apex  forwards  and  downwards,  touching  the  trian- 

1  1 


2  ENLARGEMENT  OF  THE  PROSTATE 

gular  ligament.  The  posterior  surface,  which  is  smooth  and 
slightly  grooved  in  the  middle  line,  rests  on  the  rectum,  from 
which  it  is  separated  by  dense  fibrous  tissue,  which  forms 
part  of  the  '  sheath  '  of  the  prostate. 

The  prostate  consists  of  two  lateral  lobes,  between  which 
the  ejaculatory  ducts  enter  from  behind,  before  opening  into 
the  prostatic  urethra.  A  third,  or  '  median,'  lobe  was 
described  by  Sir  Everard  Home  in  the  early  part  of  last 
century  as  existing  in  the  normal  prostate,  and  this  descrip- 
tion has  been  almost  universally  accepted  as  correct,  in  spite 
of  the  fact  that  Sir  Henry  Thompson  with  great  skill  com- 
bated the  existence  of  this  lobe.  Practical  experience  derived 
from  numerous  dissections  of  the  healthy  prostate  and  more 
than  300  operations  for  removal  of  the  enlarged  organ  entire 
in  its  capsule  has  convinced  me  that  Sir  Henry  Thompson 
was  correct  in  his  views,  and  that  the  so-called  '  middle'  lobe 
is  merely  a  pathological  product,  derived  from  one  or  both 
lateral  lobes,  and  that  it  is  non-existent  in  the  normal 
prostate.  There  is,  it  is  true,  a  median  portion,  or  bridge  of 
tissue,  sometimes  forming  a  rounded  prominence,  above  the 
ejaculatory  ducts  in  the  normal  prostate  ;  but  this  is  derived 
from  both  lateral  lobes,  which  are  in  this  position  more 
intimately  blended  than  in  the  rest  of  their  course  on  either 
side  of  the  prostatic  urethra. 

Structurally,  the  prostate  is  composed  of  glandular  sub- 
stance and  a  stroma  made  up  of  muscular  and  fibrous  tissues. 
The  glandular  substance  consists  of  follicular  pouches  with 
ducts  lined  with  columnar  epithelium.  The  excretory  ducts, 
from  twelve  to  twenty  in  number,  open  into  the  urethra 
beside  the  veru  montanum.  The  muscle  forms  the  bulk  of 
the  prostate,  its  supposed  function  being  to  eject  the 
glandular  secretion,  or  prostatic  fluid,  to  mix  with  that  from 
the  ejaculatory  ducts. 

It  is  now  recognised  that  the  prostate  is   an    accessory 


ENLARGEMENT  OE  THE  PROSTATE  3 

sexual  organ,  its  function  being  to  secrete  fluid  to  mix  with 
the  semen. 

The  prostate  has  a  tendency  to  increase  in  size  in  a  large 
proportion  of  men  after  the  age  of  fifty,  but  the  enlargement 
does  not  generally  declare  itself  by  any  marked  symptoms 
till  after  fifty-five  years.  This  rule  does  not  hold  good  in 
India,  for  it  is  generally  recognised  by  surgeons  in  that 
country  that  decided  symptoms  of  enlargement  of  the  organ 
manifest  themselves  in  natives  as  early  as  at  the  age  of  forty- 
five  years.  It  must  be  borne  in  mind,  however,  that  the 
expectation  of  life  in  Orientals  is  about  ten  years  less  than  in 
Europeans — that  is  to  say,  a  native  of  India  is  at  forty-five 
years  of  age  comparatively  as  old  a  man  physically  and 
sexually  as  a  European  is  at  fifty-five  years.  Even  in 
Europeans  we  occasionally  meet  with  instances  of  true 
enlargement  at  an  earlier  age ;  but  they  are  not  sufficiently 
numerous  to  invalidate  the  general  rule  laid  down. 

It  is  estimated  from  statistics  collected  by  the  late  Sir 
Henry  Thompson  and  others  that  about  $$  per  cent,  of  men 
beyond  fifty-five  years  of  age  are  subject  to  enlargement  of 
the  prostate,  but  that  not  more  than  5  per  cent,  ever  suffer 
from  symptoms. 

The  overgrowth  may  be  uniform  in  character,  the  hyper- 
trophy extending  equally  to  both  lobes,  the  gland  thus 
preserving  its  symmetry.  But  in  the  fully  hypertrophied 
prostate,  as  will  subsequently  appear,  the  pyramidal  contour 
of  the  organ  becomes  reversed — that  is  to  say,  whereas  in 
the  normal  prostate  the  apex  of  the  pyramid  lies  towards  the 
triangular  ligament  and  the  base  towards  the  bladder,  in  the 
hypertrophied  prostate  the  base  of  the  pyramid  lies  towards 
the  triangular  ligament,  the  apex  being  placed  in  the  bladder. 
The  manner  in  which  this  alteration  in  shape  is  gradually 
brought  about  during  the  process  of  enlargement  of  the 
organ  will  appear  later  on. 

1 — 2 


4  ENLARGEMENT  OF  THE  PROSTATE 

The  two  lobes  may  be  unequally  enlarged ;  indeed,  one 
lobe  may  be  enormously  hypertrophied,  the  other  remaining 
almost  unaltered  except  as  to  the  shape  impressed  on  it  by 
the  bulk  and  pressure  of  the  other  lobe.  The  surfaces  of  the 
lobes  may  remain  smooth  and  uniform,  but  frequently  bossy 
outgrowths  project  therefrom.  These  outgrowths  are  always 
confined  within  the  true  capsule  of  the  prostate  ;  though, 
carrying  the  capsule  before  them,  they  may  form  polypoid- 
like  outgrowths  projecting  into  the  cavity  of  the  bladder  and 
connected  with  the  main  body  of  the  organ  merely  by  narrow 
pedicles  (Fig.  i,  c,  c',  c"). 

In  size  the  enlarged  prostate  may  reach  from  anything 
beyond  the  normal  to  that  of  an  orange,  or  even  a  cocoanut. 
The  largest  prostate  that  I  have  removed  (Fig.  37)  weighed 
14.J  ounces. 

The  urethra  and  bladder  will  be  altered  in  shape  in 
accordance  with  the  size  and  form  of  the  overgrowth.  The 
prostatic  urethra  is  invariably  lengthened  and  may  attain  to 
several  inches,  so  that  15  or  16  inches  of  catheter  may  be 
introduced  before  the  urine  begins  to  flow.  When  the 
lateral  lobes  are  symmetrically  enlarged,  the  urethra  is  com- 
pressed from  side  to  side,  and  on  section  resembles  a  vertical 
slit.  When  one  lobe  only  is  enlarged,  the  urethra,  being  ■ 
diverted  to  the  opposite  side,  will  be  curved  laterally.  If 
there  be  a  median  outgrowth  in  the  bladder,  the  urethra  will 
be  curved  upwards  towards  the  inner  orifice  ;  and  if  this  be 
very  large,  pyriform,  and  projecting  into  the  bladder,  there 
will  be  a  channel  on  either  side,  the  urethra  being  Y-shaped. 
When  the  overgrowth  assumes  the  form  of  a  collar  round 
the  neck  of  the  bladder,  as  it  sometimes  does,  the  urethra 
will  necessarily  be  contracted  at  this  situation. 

The  prostate  being  debarred  from  expansion  below  by  the 
triangular  ligament,  in  its  enlargement  it  gradually  advances 
upwards  in  the  direction  of  least  resistance.     The  urethra  is 


Fig.  i.—Large  Prostate,  weighing  6  Ounces,  removed  from 
Path  n  r  vged  Seven  rv  (Case  7). 

a,  Lefi  lobe  enormously  hypertrophied ;  B,  righl  Lobe,  elongated,  flattened, 
terminating  in  outgrowths,  C,  <  '.  -  ",  in  the  bladder.  The  cathetei  lies 
in  position  of  urethra,  which  was  verytortuou 


6  ENLARGEMENT  OF  THE  PROSTATE 

carried  with  it,  and  the  inner  orifice  placed  on  a  higher  level 
than  the  base  of  the  bladder,  which  remains  stationary.  A 
post-prostatic  pouch  is  thus  formed  in  the  bladder,  which  is 
never  emptied  of  urine  during  the  acts  of  micturition.  This 
remaining  quantity  of  urine,  which  is  termed  'residual,' 
gradually  increases  in  quantity  as  the  hypertrophy  pro- 
gresses and  the  muscular  power  of  the  bladder  diminishes, 
owing  to  the  persistent  overstrain  that  the  organ  is  subjected 
to  in  order  to  overcome  the  obstruction  to  the  flow  of  urine. 
In  the  early  stages  of  the  disease  there  is  a  compensator)' 
hypertrophy  of  the  bladder  walls  to  overcome  this  obstruc- 
tion, but  in  time,  owing  to  the  constant  straining,  dilatation 
ensues,  so  that  the  bladder  may  contain  several  pints  of 
urine.  The  walls  may  become  extremely  thin,  or  muscular 
trabecular  may  develop,  between  which  the  mucous  mem- 
brane bulges  outwards,  forming  saccules  of  various  sizes. 
In  course  of  time  changes  occur  in  the  ureters  and  kidneys 
from  the  backward  pressure  due  to  the  obstruction  of  the 
urinary  flow- — changes  similar  to  those  taking  place  in  con- 
nection with  stricture  of  the  urethra.  Haemorrhoids  and 
prolapsus  ani  also  occur  frequently  in  connection  with  this 
disorder  from  the  constant  straining  in  micturition. 

Theoretical  Causes  of  Prostatic  Enlargement. 

Many  theories  have,  from  time  to  time,  been  put  forward 
to  account  for  the  enlargement  of  the  prostate  peculiar  to 
declining  life,  none  of  which,  however,  can  be  said  to  fit 
completely  with  all  the  phenomena  attending  this  disorder. 
I  shall  confine  myself  to  stating  briefly  some  of  the  rival 
views. 

Guyon  and  the  French  school  generally  maintained,  at 
least  till  quite  recently,  that  the  enlargement  of  the  prostate 
is  not  a  purely  local  disease  ;  that  it  is  merely  a  local  mani- 
festation of  a  constitutional  disorder  which  commences  with 


ENLARGEMENT  OF  THE  PROSTATE  7 

general  arterial  sclerosis  and  ends  in  fibroid  degeneration  ; 
that  the  genito-urinary  organs — prostate,  bladder,  ureters, 
and  kidneys — are  liable  to  undergo  this  change  in  a  pro- 
nounced form,  the  muscular  and  glandular  structures  being 
replaced  by  dense  fibrous  tissue,  but  that  these  latter  changes 
are  never  independent  of  general  atheroma.  The  enlarge- 
ment of  the  prostate  and  changes  already  described  as  taking 
place  in  the  urinary  tract  behind  are  held  to  be  coincident 
and  not  related  to  each  other  as  cause  and  effect.  It  is 
pointed  out  in  this  connection  that  all  the  symptoms  com- 
monly regarded  as  the  result  of  hypertrophy  of  the  prostate 
may  occur  when  there  is  no  enlargement  of  that  organ,  as  a 
result  of  sclerosis  of  the  bladder. 

Against  this  theory  it  is  urged,  that  the  fact  that  atheroma 
and  enlargement  of  the  prostate  occur  together  is  no  proof 
that  the  latter  is  the  result  of  the  former — as  well  might 
cancer  and  other  diseases  which  are  liable  to  occur  during 
the  atheromatous  age  be  attributed  to  this  degeneration  ; 
that  enlargement  of  the  prostate  occurs  when  there  is  no 
such  general  atheroma  of  the  system  ;  that  arterial  sclerosis 
induces  atrophy  rather  than  hypertrophy  ;  that  enlarge- 
ment of  the  prostate  frequently  commences  before  the 
atheromatous  period  ;  and  that  this  enlargement  always 
commences  as  adenomatous  overgrowth,  and  not  as  fibroid 
degeneration. 

One  of  the  most  important  effects,  from  a  surgical  point 
of  view,  of  the  acceptance  of  Guyon's  theory,  if  carried  to 
its  logical  conclusion,  would  be  to  prohibit  the  employment 
of  any  form  of  operative  interference  aimed  at  the  radical 
cure  of  the  disease — to  limit  the  treatment,  in  fact,  to  the 
palliative  kind. 

Another  theory  is  that  propounded  by  Velpeau,  and  till 
rei  ently  supported  by  some  of  the  highest  authorities  in  this 
country  and  America,  notably  Thompson  and  White— via., 


8  ENLARGEMENT  OF  THE  PROSTATE 

that  enlargement  of  the  prostate  is  analogous  to  fibroid 
disease  of  the  uterus.  In  support  of  this  view  it  is  pointed 
out  that  the  utricle  of  the  prostate  is  the  equivalent  of  the 
uterus  (and  vagina)  ;  that  the  structure  of  the  prostate  and 
uterus  are  somewhat  similar;  that  there  is  a  great  resemblance 
in  structure,  position,  and  mode  of  growth  between  the  fibro- 
myomata  found  in  the  uterus  and  the  overgrowths  that 
constitute  enlarged  prostate  ;  and  that  the  disease  in  both 
instances  sets  in  when  sexual  activity  is  on  the  wane,  and 
does  not  originate  when  that  activity  has  completely  ceased. 

In  opposition  to  this  view  are  advanced  the  facts  that  the 
utricle,  which  is  the  true  analogue  of  the  uterus,  takes  no 
active  part  in  the  prostatic  enlargement,  and  that  the  uterine 
tumours  commence  as  fibro-myomata,  whereas  the  prostatic 
overgrowths  originate  as  adenomata. 

The  theory  that  enlargement  of  the  prostate  is  of  inflam- 
matory origin  dates  back  to  the  days  of  John  Hunter,  who 
advanced  this  view.  Virchow  also  held  the  same  opinion. 
Many  papers  have  been  published  in  the  past  few  years 
advocating  this  theory.  But  its  ablest  champion  is  Ciecha- 
nowski,  who  explains  the  sequence  of  events  as  follows  :  '  A 
catarrhal  process  occurs  in  the  acini,  producing  active  pro- 
liferation, desquamation,  and  degeneration  of  the  epithelium  ; 
at  the  same  time  a  productive  change  takes  place  in  the 
stroma,  which  compresses  the  excretory  ducts  of  the  acini, 
narrowing  or  obliterating  them.  The  latter  prevents  the 
escape  of  the  contents,  the  secretions  accumulate  within  the 
acini,  and  the  lobules  enlarge.  The  prostatic  urethra  is  said 
to  be  the  origin  of  the  disease,  which  extends  thence  along 
the  gland  ducts  from  the  urethra  towards  the  periphery  of 
the  prostate.' 

The  advocates  of  this  theory  hold  that  the  disease  is  con- 
fined mainly  to  persons  who  have  suffered  from  posterior 
urethritis  previously,  whether  due  to  gonorrhoea,  masturbation, 


ENLARGEMENT  OF  THE  PROSTATE  9 

or  sexual  excess  (whether  natural  or  unphysiological).  But 
they  entirely  fail  to  explain  how  it  happens  that  the  enlarge- 
ment of  the  prostate  does  not  occur  during  that  period  of 
life — viz.,  early  manhood — when  these  diseases  and  conditions 
that  are  held  to  be  the  cause  prevail,  except  that  the  process 
remains  latent  for  years  till  even  the  existence  of  the  pro- 
voking conditions  has  in  many  instances  faded  from  the 
memory. 

I  have  in  many  hundreds  of  cases  of  enlarged  prostate 
inquired  carefully  into  the  previous  history  of  each  person, 
and  my  experience  goes  to  show  that  the  previous  mode  of 
life  of  the  patient  has  nothing  whatever  to  do  with  the 
advent  of  this  disease.  It  occurs  with  equal  frequency  in 
those  who  have  suffered  from  urethritis  and  those  who  have 
not  ;  in  the  married  and  unmarried  ;  in  the  continent  and 
those  who  have  indulged  in  sexual  excess ;  in  persons  of 
sedentary  as  of  active  habits ;  in  the  gourmand  as  in  him 
who  has  eaten  sparingly  all  his  life. 

All  we  know  of  the  disease  is  that  the  enlargement  of  the 
gland  is  mainly,  if  not  wholly,  of  an  adenomatous  character, 
and  that  it  occurs  only  during  the  decline  of  life  when  the 
sexual  functions  are  on  the  wane.  Having  fulfilled  its  purpose 
as  an  accessory  sexual  organ  in  early  and  mature  manhood, 
as  its  function  diminishes  the  gland  has  a  tendency  in  disease 
to  '  run  to  seed,'  as  it  were,  in  assuming  this  unhealthy 
adenomatous  overgrowth  ;  but  why  it  does  so  has  yet  to  be 
explained. 

It  is  true,  as  will  subsequently  appear,  that  the  usual 
symptoms  of  enlarged  prostate  may  occasionally  be  induced 
in  advanced  life  by  an  attack  of  inflammation,  or  even  con- 
gestion, of  the  prostate;  but  in  such  cases  there  is  practically 
no  enlargement  of  the  organ  at  all,  and  certainly  no  enlarge- 
ment of  an  adenomatous  nature  as  in  true  prostatic  hyper- 
trophy of  declining  life. 


io  ENLARGEMENT  OF  THE  PROSTATE 

Symptoms. 

We  now  come  to  the  symptoms  of  enlarged  prostate.  A 
man  aged  over  fifty  years  consults  you  because  (i)  he  finds 
that  for  some  time  he  has  suffered  from  increased  frequency 
of  micturition  which  troubles  him  more  at  night  than  through- 
out the  day;  (2)  he  has  some  difficulty  in  starting  the  stream; 
(3)  there  is  diminution  in  the  strength  of  the  urinary  flow, 
which,  instead  of  being  projected  in  the  normal  curve,  falls 
directly  downwards  from  the  meatus  simply  by  its  own 
weight ;  (4)  he  strains  to  propel  the  urine  onwards,  but  his 
efforts  have  little  or  no  effect  in  strengthening  the  stream ; 
on  the  contrary,  the  straining  may  arrest  the  flow  com- 
pletely ;  (5)  there  is  incomplete  stoppage,  as  indicated  by 
dribbling  at  the  end  of  micturition ;  and  (6)  there  may  be 
intermittency  of  the  flow  due  to  the  ball-valve  action  of  the 
outgrowth  in  the  bladder.  If  the  patient  does  not  complain 
of  pain,  beyond,  perhaps,  an  undefined  aching  about  the 
perineum,  and  there  is  no  haematuria,  the  case  is  in  all 
probability  one  of  enlargement  of  the  prostate  in  a  com- 
paratively early  stage. 

It  will  be  observed  that  none  of  the  symptoms  are  referable 
to  the  prostate  itself.  They  are  attributable  to  interference 
with  the  functions  of  the  urethra  and  bladder  caused  by 
changes  in  the  gland,  which  are  so  gradual  that  they  do  not 
cause  pain  like  inflammation  or  malignant  disease.  As  the 
disease  progresses,  unless  relieved  by  art,  all  the  symptoms 
are  aggravated,  and  others,  notably  pain  and  haematuria, 
supervene. 

In  the  early  stages  of  the  disorder  the  increased  frequency 
of  micturition  is  due  to  some  outgrowth  at  the  neck  of  the 
bladder,  which  acts  as  an  irritant,  like  a  foreign  body,  to  this 
the  most  sensitive  portion  of  the  organ.  Local  congestion  or 
even  inflammation  of  the  mucous  membrane  ensues,  and  this 


ENLARGEMENT  OF  THE  PROSTATE  n 

induces  further  frequency.  Later,  another  factor  comes  into 
play :  a  post-prostatic  pouch  is  formed  in  which  a  gradually 
increasing  quantity  of  urine  is  retained  after  micturition. 
This  retained  urine  is,  as  we  have  already  seen,  termed 
'  residual,'  and  the  manner  in  which  it  causes  increased 
frequency  requires  some  explanation. 

The  bladder  is  a  reservoir  capable  of  containing  a  certain 
quantity  of  fluid,  which  is  voluntarily  discharged  at  con- 
venient intervals.  Let  us  assume  that  the  quantity  passed 
in  twenty-four  hours  is  50  ounces,  and  that  the  capacity  of 
the  bladder  is  10  ounces.  It  will  thus  be  necessary  to  empty 
the  bladder  at  least  five  times  in  the  twenty-four  hours.  But 
if,  the  actual  capacity  remaining  the  same,  a  pouch  is  formed 
in  the  bladder  containing,  say,  4  ounces  of  urine  that  is  never 
expelled,  it  follows  that  the  effective  capacity  is  reduced  to 
6  ounces,  so  that  in  order  to  get  rid  of  the  50  ounces  that 
daily  flow  into  it  the  bladder  must  be  discharged  of  these 
6  ounces  about  eight  times.  As  the  pouch  enlarges  and  the 
bladder  walls  grow  weaker  the  quantity  of  fluid  permanently 
retained  increases  and  its  effective  capacity  diminishes,  so 
that  eventually  micturition  has  to  take  place  every  half-hour 
or  even  less.  Indeed,  this  condition  may  advance  to  such  an 
extent  that  the  bladder  is  incapable  of  discharging  any  urine 
whatever,  when  we  have  another  symptom — viz.,  continuous 
dribbling — the  urine  passing  away  by  day  and  night  as  rapidly 
as  it  enters  the  bladder,  but  the  latter  always  remaining  full. 
The  urine  passing  in  this  condition  is  termed  the  '  overflow,' 
and  has  to  be  distinguished  from  '  incontinence,'  a  rare 
occurrence  in  certain  spinal  complaints  in  which  the  urine 
runs  away  from  an  empty  bladder. 

The  frequency  of  micturition  is,  as  already  stated,  worse  at 
night,  or,  rather,  towards  the  latter  part  of  the  night,  and  in 
the  early  morning  <>n  rising  ;  in  this  respect  contrasting  with 
the  frequency  due  to  stone,  which  is  always  worse  in  the  day- 


12  ENLARGEMENT  OF  THE  PROSTATE 

time  when  the  patient  is  going  about.  Why  this  should  be 
so  has  not  as  yet  been  satisfactorily  explained.  It  cannot  be 
due  to  the  recumbent  position  alone,  for  it  does  not  occur  in 
the  daytime  if  the  patient  keeps  lying  down,  provided  he 
remains  awake.  It  may,  as  has  been  suggested,  be  due  to 
the  fact  that  during  the  first  sleep  of  the  night  the  bladder  is 
not  relieved  for  a  longer  period  than  usual.  Distension  of  the 
bladder  results,  with  congestion,  giving  rise  to  increased 
frequency,  which  does  not  cease  for  some  hours  till  the 
congestion  has  subsided. 

The  urine  in  the  early  stages  of  the  disorder  is  clear  and 
acid.  The  quantity  will  probably  be  increased  and  the  specific 
gravity  be  lowered — changes  due  to  fibroid  degeneration  of 
the  kidneys  met  with  in  elderly  persons,  particularly  when 
prostatic  obstruction  is  also  present.  As  the  disease  advances 
the  urine  becomes  cloudy  and  gives  off  a  fishy  odour.  Sooner 
or  later  the  urine  has  a  tendency  to  decompose,  whether  as  a 
contingency  of  catheterism  or  otherwise,  cystitis  sets  in,  and 
pus  is  deposited  on  the  bladder  walls  in  thick  flakes.  This 
condition  is  favourable  to  the  formation  of  phosphatic  calculi, 
which  are  a  frequent  complication  of  enlarged  prostate,  lying 
in  the  post-prostatic  pouch  or  in  the  cysts  formed,  as  already 
described,  by  the  bulging  out  of  the  mucous  membrane 
between  the  muscular  trabecule. 

Diagnosis. 

With  the  presence  of  symptoms  that  point  to  the  probable 
existence  of  enlargement  of  the  prostate  we  proceed  to  verify 
our  diagnosis  by  a  physical  examination  of  the  urethra  and 
rectum. 

The  patient  is  first  directed  to  pass  all  the  urine  he  can, 
and  we  note  the  strength  and  general  character  of  the  stream. 
He  is  then  placed  on  his  back  on  a  couch  ;  the  glans  and 
foreskin  are  thoroughly  washed  with    an  antiseptic,  and  a 


ENLARGEMENT  OF  THE  PROSTATE 


13 


catheter,  13  or  14  of  the  French  scale  (7  or  8  E.),  is  slowly 
and  carefully  introduced.  Our  choice  of  catheters  will  lie 
between  a  Jaque's  vulcanized  rubber  (Fig.  2),  a  very  pliant 
cylindrical  gum-elastric,  or  a  French  coudee  (Fig.  3). 
This  latter  is,  as  a  rule,  the  most  easily  introduced.  It 
should  be  held  almost  horizontally  at  first,  with  the  curved 
point  turned  downwards,  and  gradually  elevated  into  the  per- 
pendicular position  as  the  instrument  passes  onwards  through 
the  urethra  and  into  the  bladder.  It  should  be  noted  if  there 
be  any  obstruction  at  the  neck  of  the  bladder,  and  if  the  end 
of  the  catheter  rides  over  it,  which  would  probably  indicate  a 


Fig. 


Fig. 


prostatic  outgrowth  in  the  bladder.  The  quantity  of  urine 
drawn  off,  if  any,  indicates  the  amount  of  'residual'  urine. 
This  will  vary  from  a  few  drachms  to  3  or  4  pints,  according 
to  the  stage  the  disease  has  reached  when  the  patient  first 
comes  under  examination.  If  the  quantity  be  considerable 
he  will  express  surprise,  seeing  that  he  had  just  previously 
passed  urine,  and  was  under  the  impression  that  he  had 
emptied  his  bladder.  If  the  quantity  of  urine  be  large,  the 
whole  of  it  should  not  be  drawn  off  at  the  first  interview,  lest 
the  patient  may  faint,  or  haemorrhage  set  in  from  the  vessels 
of  the  bladdei  giving  way  through  loss  of  their  habitual 
support.  If  the  quantity  be  moderate,  a  second  or  third 
examination    should   be   made   to  avoid   error  as   to  the   real 


i4  ENLARGEMENT  OF  THE  PROSTATE 

amount  of  the  '  residual '  urine.  Before  introducing  the 
catheter  the  hypogastric  region  should  be  palpated,  for  in 
this  way  it  may  at  once  be  recognised  that  the  bladder  is 
distended  with  urine. 

We  next  make  a  digital  examination  of  the  rectum.  The 
forefinger  is  lubricated,  the  crevice  beneath  the  nail  having 
been  previously  filled  with  soap,  and  introduced  slowly  and 
gently  to  avoid  giving  pain,  and  a  careful  survey  of  the 
prostate  is  made.  The  extent  of  the  enlargement,  if  any, 
should  be  noted,  and  whether  this  is  general,  or  confined 
more  to  one  side  than  the  other ;  whether  the  contour  of  the 
gland  is  smooth  or  nodulated ;  what  its  consistency,  whether 
soft,  indicating  adenomatous  enlargement,  or  hard  from 
inflammatory  fibroid  overgrowth ;  also  if  pressure  on  the 
gland  gives  pain,  and,  if  so,  to  what  degree.  Much  pain 
with  fluctuation  would  suggest  the  probability  of  abscess, 
particularly  if  the  patient  has  had  fever  recently.  Intense 
hardness  with  nodulation  would  suggest  malignant  disease  ; 
and  a  very  hard  nodule  in  the  substance  of  the  gland,  accom- 
panied by  tenderness  on  pressure,  the  presence  of  a  calculus 
in  the  organ.  The  finger  should  pass  beyond  the  gland  if 
possible,  and  sweep  the  base  of  the  bladder,  to  ascertain  if 
this  is  normally  soft,  or  hard  from  cancerous  infiltration. 
Possibly  a  stone  may  be  felt  in  the  post-prostatic  pouch. 
The  examination  will  be  facilitated  by  making  counter- 
pressure  on  the  abdomen  above  the  pubes  with  the  other 
hand. 

The  patient  should  next  be  placed  on  his  knees  on  the 
couch,  with  his  head  bent  forwards  and  downwards,  and  the 
buttocks  rendered  prominent  by  the  thighs  being  flexed  on 
the  legs.  The  finger  is  again  introduced  and  the  rectum 
surveyed  as  before.  This  position  renders  the  prostate  more 
prominent  in  the  rectum  than  the  recumbent  one,  and  the 
finger  can  be  introduced  farther.     The  impressions  conveyed 


ENLARGEMENT  OF  THE  PROSTATE  15 

to  the  finger  in  both  positions  are  contrasted,  and  important 
information  may  thus  be  acquired. 

Little  information  with  reference  to  the  condition  of  the 
amount  of  outgrowth  in  the  bladder  will  be  gained  by  rectal 
examination.  In  fact,  there  may  be  great  outgrowth  of  the 
prostate  into  the  cavity  of  the  bladder  when  no  enlargement 
of  the  gland  is  recognised  by  the  rectum.  It  will,  as  a  rule, 
be  desirable  to  ascertain  the  extent  and  form  of  this  enlarge- 
ment. A  rough  estimate  can  be  arrived  at  by  the  introduc- 
tion of  a  short-beaked  sound.  When  the  instrument  has 
entered  the  bladder,  the  handle  is  depressed  between  the 
thighs,  and  the  beak  rotated  to  one  side  and  then  to  the 
other,  feeling  on  which  side  of  the  instrument  the  enlarge- 
ment lies,  and  to  what  extent  it  projects  into  the  bladder.  If 
the  finger  be  introduced  into  the  rectum  whilst  the  sound  is 
in  the  bladder,  a  rough  idea  of  the  size  of  the  outgrowth  may 
be  formed. 

Examination  of  the  bladder  by  the  cystoscope  will  in  a 
large  proportion  of  cases  give  a  still  more  correct  estimate  of 
the  size  and  shape  of  the  outgrowth,  and  as  to  whether  or 
not  the  gland  is  capable  of  being  removed  by  operation  in  a 
manner  that  will  be  described  later.  At  our  first  visit,  how- 
ever, it  will  not  be  advisable  to  employ  either  sound  or 
cystoscope.  This  should  always  be  deferred  to  a  later  inter- 
view, when  the  patient  should  be  examined  in  his  own  room. 
At  the  first  visit  we  rest  content  with  the  information  gained 
by  the  catheter  and  by  rectal  examination,  taken  in  connection 
with  the  general  symptoms. 

After  examination  the  patient  should  go  home  and  to  bed 
for  the  day.  Indeed,  when  the  case  is  at  all  far  advanced 
and  the  patient  feeble,  it  will  be  advisable  to  postpone  the 
introduction  of  even  a  catheter  till  he  is  in  his  own  room. 


LECTURE  II 

GENERAL  TREATMENT  OF  ENLARGED  PROSTATE  AND 
ITS  COMPLICATIONS 

Passing  on  to  the  treatment  of  enlargement  of  the  prostate, 
you  are  aware  that  in  this  field  of  research  considerable 
activity  has  been  displayed  by  surgeons  in  recent  years  as 
regards  operative  interference.  Holding,  as  I  do,  that  in 
the  vast  majority  of  cases  of  this  malady  there  is  only  one 
form  of  treatment  worthy  of  consideration — viz.,  total  enuclea- 
tion of  the  diseased  organ — the  time  has  not  yet  come,  and 
probably  never  will,  when  the  employment  of  the  catheter 
can  be  entirely  dispensed  with  in  practice.  It  is  to  its 
judicious  use  that  I  shall  in  large  part  direct  your  attention 
in  this  lecture,  at  the  same  time  referring  to  other  subjects 
connected  with  the  general  management  of  the  disease  under 
consideration. 

When  enlargement  of  the  prostate  is  unattended  by  any 
symptoms,  no  treatment  is  necessary.  If,  however,  decided 
symptoms  of  obstruction  are  present,  but  the  bladder  contains 
no  '  residual '  urine,  or  only  an  ounce  or  two,  the  question 
arises  as  to  what  treatment,  if  any,  is  desirable.  In  such 
cases  I  am  in  the  habit  of  passing  a  large  steel  dilator 
(Fig.  4)  as  far  as  the  bladder  once  a  week,  and  leaving  it  in 
position  for  ten  or  twelve  minutes,  commencing  with  a 
No.  11  or  No.  12,  English  scale,  and  gradually  advancing  to 
No.  15  or  No.  16.     I  entirely  concur  in  the  opinion  of  my 

16 


GENERAL  TREATMENT  OF  ENLARGED  PROSTATE      17 

colleague,  Mr.  Reginald  Harrison,  as  to  the  beneficial  effect 
of  this  simple  procedure.  It  probably  does  not  stay  the 
progress  of  the  disease,  but  the  periodical  introduction  of  the 
dilator  causes  absorption  of  the  gland  around  the  urethra  and 
maintains  the  patency  of  the  channel,  thus  staving  off  for 
an  indefinite  period  the  necessity  of  having  recourse  to  habitual 
catheterism. 

It  is  customary  in  cases  of  this  kind  in  the  incipient  stage 
of  enlargement  to  administer  ergot,  with  a  view  to  causing 
reduction,  or  retarding  the  advance,  of  the  outgrowth.  I  am 
in  the   habit  of  employing  the  liquid  extract  of  this  drug 


Fig.  4. 

combined  with  a  saline,  both  in  hospital  and  private  practice. 
It  is  difficult  to  say  definitely  whether  the  ergot  has  any 
effect  in  staying  the  advance  of  the  enlargement,  but  it  seems 
to  relieve  congestion,  and  patients  undoubtedly  express  them- 
selves as  improved  under  its  administration. 

It  will,  as  a  rule,  be  unnecessary  to  have  recourse  to  the 
habitual  use  of  the  catheter  till  the  residual  urine  amounts  to 
between  3  and  4  ounces ;  but  if  the  frequency  of  micturition 
at  night  is  such  as  to  affect  injuriously  the  patient's  health 
through  want  of  sleep,  it  will  be  desirable  to  commence 
earlier.  When,  however,  about  4  ounces  of  residual  urine 
have  been  reached,  habitual  catheterism  must  be  employed, 
and  the  patient  enters  on  what  is  termed  'catheter  life,'  from 
which  he  can  scarcely  ever  recede  without  an  operation.  When 
the  '  residual '  urine  is  limited  to  4  ounces  or  less,  it  will,  as 
a  rule,  be  sufficient  to  pass  the  catheter  once  in  the  twenty-four 
hours,  and  the  best  time  for  doing  this  is  at  bedtime,  so  that 

2 


1 8     GENERAL  TREATMENT  OF  ENLARGED  PROSTATE 

he  may  have  several  hours  of  sleep  afterwards.  If  6  ounces 
are  retained,  the  catheter  should  be  employed  twice  daily;  if 
8  or  io  ounces,  three  or  four  times  daily.  When  all  power 
of  voluntary  micturition  is  lost,  the  catheter  must  be  used 
whenever  the  desire  for  urination  is  decidedly  felt,  generally 
every  four  hours  or  so.  On  no  account  should  the  patient 
be  limited  to  any  specific  time  within  which  he  should  not 
employ  the  catheter.  The  urine  should  be  drawn  off  before 
pain  or  marked  discomfort  is  felt,  otherwise  congestion  of 
the  prostate  and  bladder  resulting  in  cystitis  will  be  produced. 

The  patient  must  be  taught  how  to  use  the  catheter,  and 
he  should  never  be  without  one — that  is  to  say,  if  he  leaves 
home  on  a  journey,  or  in  the  course  of  his  ordinary  occupa- 
tion, he  should  always  carry  one  about  with  him,  for  he  may 
find  at  any  time  that  its  employment  is  imperative.  Indeed, 
the  sooner  the  patient  recognises  that  the  primary  duty  of 
his  life,  under  such  circumstances,  is  the  employment  of  his 
catheter  the  better. 

A  soft  coudee  catheter  (Fig.  3),  No.  7  to  9  E.,  whichever 
passes  most  easily,  is,  as  a  rule,  the  best  for  habitual 
employment.  The  patient,  unless  very  infirm,  passes  it 
standing.  There  is  now  no  danger  of  syncope,  for  the 
quantity  of  urine  allowed  to  accumulate  is  limited,  and  during 
the  period  of  instruction  in  the  use  of  the  catheter  that  he 
will  have  undergone  at  the  hands  of  the  surgeon  he  will  have 
acquired  confidence  in  its  use.  The  instrument  is  held  per- 
pendicularly whilst  its  end  is  introduced  into  the  urethra. 
It  is  then  gradually  depressed  into  the  horizontal  position, 
as  it  glides  along  the  canal  over  the  obstruction  and  into  the 
bladder,  the  curved  end  being  directed  upwards  towards  the 
roof  of  the  urethra.  Sometimes  a  well-polished  vulcanized 
rubber  catheter  (Fig.  2)  answers  best.  A  timid  patient  likes 
it,  as  less  liable  to  pain  him  ;  but  if  the  prostatic  urethra  is 
narrowed  from  pressure  of  the  lateral  lobes  it  is  not  so  easy 


GENERAL  TREATMENT  OF  ENLARGED  PROSTATE      19 

to  introduce  as  a  more  rigid  instrument.  It  has  also  the  dis- 
advantage that,  its  walls  being  stout,  the  channel  is  com- 
paratively narrow,  so  that  the  urine,  if  at  all  thick,  will  not 
flow  through  it  readily.  On  the  other  hand,  as  it  can  be 
boiled  without  injury,  it  is  readily  rendered  aseptic,  and  as  it 
coils  up  in  a  small  space  it  can  be  carried  about  very  easily. 
A  soft  and  pliant  cylindrical  catheter  will  pass  readily  and 


Fig.  5. 


Fig.  6. 

answer  best  when  there  is  no  obstruction  caused  by  the 
outgrowth  in  the  bladder.  When  this  outgrowth  is  very 
marked,  a  bicoudee  catheter  (Fig.  5),  or  a  well-curved  one 
terminating  in  a  coude  (Fig.  6),  may  be  necessary  to  over- 
come the  obstruction.  Formerly  it  was  customary  to  keep 
catheters  mounted  on  a  well-curved  metal  stylet  ready  for  use ; 
they  are  now  woven  with  this  curve  in  their  manufacture 
and  retain  their  shape  permanently. 

2—2 


20      GENERAL  TREATMENT  OF  ENLARGED  PROSTATE 

It  will  be  rarely  desirable  for  a  patient  himself  to  pass  a 
metal  catheter.  When  circumstances  arise  requiring  its 
employment,  the  surgeon  should  be  called  in. 

Whatever  instrument  is  employed  it  must  be  kept  scrupu- 
lously clean.  The  life  and  comfort  of  the  patient  depend 
not  less  on  the  cleanliness  of  his  catheter  than  on  the 
judicious  use  of  the  same.  It  will  not  be  out  of  place,  there- 
fore, if  I  here  direct  your  attention  to  the  antiseptic  precau- 
tions necessary  in  the  employment  of  urethral  instruments  in 
general. 

The  instruments  required  for  catheterism  are  of  three  kinds 
— metallic,  soft  rubber,  and  gum-elastic.  The  first  two  are 
most  easily  and  effectually  sterilized  by  boiling.  They  should 
be  thoroughly  washed  and  syringed  through  with  soap  and 
warm  water,  and  then  boiled  for  ten  minutes,  after  which 
they  are  transferred  to  boric  lotion  ready  for  use.  Gum- 
elastic  instruments  cannot  be  boiled  without  injury.  They 
are  best  cleansed  by  washing  and  syringing  them  through 
with  soap  and  warm  water,  and  then  placing  them  in  a 
i  in  40  solution  of  carbolic  acid  for  ten  minutes,  after  which 
they  are  placed  in  boric  lotion  before  use.  Prolonged  ap- 
plication of  strong  antiseptics  renders  them  rough  and 
dangerous. 

Before  introducing  an  instrument  of  any  kind  into  the 
bladder,  the  foreskin  and  glans  should  be  well  washed  with 
soap  and  warm  water,  and  then  swabbed  with  some  weak 
antiseptic  lotion.  If  there  be  any  discharge  from  the  urethra, 
the  anterior  part  of  the  canal  should  be  syringed  out  with 
warm  boric  lotion,  but  otherwise  this  precaution  is  un- 
necessary. Bacteriologists  tell  us  that  even  the  healthy 
urethra  swarms  with  organisms  that  cannot  be  completely 
got  rid  of  by  the  most  thorough  irrigation  by  antiseptic 
lotions,  so  that,  theoretically  speaking,  the  introduction  of 
an  instrument  into  the  bladder  ought  to  be  attended  fre- 


GENERAL  TREATMENT  OF  ENLARGED  PROSTATE    21 

quently  by  infection  of  the  urine.  Clinical  experience,  how- 
ever, teaches  us  that  with  the  simple  precautions  indicated 
this  may  be  avoided. 

It  is  useless  to  lay  down  an  elaborate  ritual  of  urinary 
asepsis  which  cannot  be  followed  out  in  practice  by  the 
patient  himself.  If  we  only  reflect  on  the  frequency  with 
which  a  man  who  has  entered  on  catheter  life  has  to  pass  an 
instrument,  and  the  circumstances  under  which  he  has  often 
to  do  so,  it  is  obvious  that  the  means  of  keeping  his  catheter 
aseptic,  to  be  efficient,  must  be  as  simple  as  possible.  For- 
tunately in  soap  and  water  we  have  an  efficient,  convenient, 
and  practical  method  of  cleansing  catheters,  and  this  is  what 
most  patients  have  to  rely  on,  and  that  with  impunity.  After 
using  the  catheter  it  should  be  again  washed  as  before, 
thoroughly  dried,  and  then  placed  for  future  use  in  a  corked 
glass  tube  or  covered  dish.  The  best  way  of  drying  soft 
catheters  is  by  pressing  them  between  folds  of  lint  or  gauze, 
in  which  they  may  be  kept  till  again  required. 

The  powerful  antiseptic  properties  of  trioxymethylene, 
a  white  powder  obtained  by  evaporation  of  formol,  have 
recently  been  taken  advantage  of  on  the  Continent  for 
sterilizing  gum-elastic  catheters.  This  powder  gives  off 
slowly  a  vapour  which  is  really  formol  in  its  gaseous  form. 
If  the  catheters  be  placed  quite  dry  on  trays  in  an  air-tight 
box  (Fig.  7)  with  this  powder  enclosed  between  folds  of  lint, 
they  are  rendered  quite  aseptic  in  twenty-four  hours  by  the 
vapour  given  off.  Before  use  they  should  be  placed  in  boric 
lotion,  as  the  formol  is  slightly  irritant  to  the  mucous  mem- 
brane of  the  urethra.  The  catheters  can  also  be  sterilized  in 
a  glass  tube  fitted  with  a  cork  (Fig.  8)  containing  the  powder, 
which  evaporates  through  a  fine  grating  on  its  inner  aspect. 

As  lubricants  for  instruments,  fresh  olive-  or  castor-oil  or 
vaseline  may  be  used.  Carbolic  acid  should  not  be  added  ; 
it  irritates  the  mucous  membrane  if  the  proportion  used  be 


22      GENERAL  TREATMENT  OF  ENLARGED  PROSTATE 


I 


'JZ  SCALE 


w 

H 
CO 

Pi 
W 
H 

« 
U 


of  any  strength,  and  weak  carbolized  oil  has  practically  no 
sterilizing  effect.     Guyon's  pomade,  composed  of  equal  parts 


GENERAL  TREATMENT  OF  ENLARGED  PROSTATE      23 

of  glycerine,  powdered  soap,  and  water  with  1  per  cent,  of 
phenol  or  naphthol,  is  a  clean  and  efficient  lubricant. 

The  general,  or  hygienic,  treatment  is  most  important. 
The  diet  should  be  light,  simple,  and  nutritious.  Vegetables 
and  fruit,  particularly  baked  or  stewed  apples,  should  be 
taken  regularly ;  but  tomatoes,  asparagus,  and  rhubarb 
should  be  avoided,  as  they  act  as  irritants  to  the  urinary 
tract.  The  less  stimulants  taken  the  better.  The  clothing 
must  be  adapted  to  avoid  cold  ;  the  patient  should  be  swathed 
in  flannel.  Sitting  on  cold  or  wet  seats  should  be  particu- 
larly avoided,  to  guard  against  congestion  of  the  prostate. 
The  daily  warm  bath,  best  taken  at  bedtime,  promotes  the 
action  of  the  skin  and  relieves  local  congestion  about  the 
prostatic  region.  The  most  important  part  of  the  general 
treatment  is  the  regulation  of  the  bowels.  If  they  become 
at  all  constipated  the  urinary  symptoms  are  aggravated. 
Measures  should,  therefore,  be  taken  to  induce  a  soft,  but 
not  liquid,  motion  daily.  There  is  nothing  better  than  con- 
fection of  sulphur  or  senna,  or  equal  parts  of  both.  Aloin, 
liquorice-powder,  and  the  sulphate  of  soda  are  useful,  or  one 
of  the  natural  bitter  saline  waters  may  be  taken  in  the 
morning.  The  enema  should  always  be  at  hand  for  use  in 
case  medicines  should  fail  to  induce  a  daily  motion.  If 
pain  be  present,  an  opiate  must  be  given  by  the  mouth, 
hypodermically,  or  as  a  suppository.  On  no  account  should 
belladonna  be  administered  whilst  the  bladder  retains  any 
vestige  of  expulsive  power,  owing  to  its  paralyzing  influence 
on  the  muscles  of  that  organ.  Walking  or  carriage  exercise 
should  be  taken  daily,  rough  roads  being  avoided ;  but  riding 
on  horseback  or  on  a  bicycle  should  be  abandoned  on 
account  of  the  shaking  or  direct  pressure  on  the  prostate 
caused  thereby.  The  patient  should  as  far  as  possible  pursue 
his  ordinary  avocation  and  pleasures,  but  sexual  excitement 
should  be  avoided. 


24      GENERAL  TREATMENT  OF  ENLARGED  PROSTATE 

Complications  and  Difficulties. 

There  are  certain  difficulties  and  complications  incident  to 
catheter  life  to  which  I  will  now  direct  your  attention. 

When  the  surgeon  is  consulted  at  a  comparatively  early 
stage  of  the  disorder,  before  the  residual  urine  amounts  to 
more  than  a  few  ounces,  if  careful  asepsis  be  employed  in 
the  introduction  of  instruments,  the  entry  on  catheter  life  is 
effected  without  any  constitutional  or  local  disturbance,  and 
matters  run  smoothly. 

If,  however, — and  this  is  what  happens  in  a  large  propor- 
tion of  cases  that  come  under  observation, — through  wrong 
advice,  or  that  timidity  about  consulting  the  surgeon  that 
induces  elderly  men  suffering  from  urinary  troubles  to  put 
off  what  they  regard  as  the  evil  day  as  long  as  possible,  the 
symptoms  have  existed  for  a  long  time,  there  is  difficulty 
and  frequency  of  micturition  with  some  pain,  the  urine  is 
turbid,  possibly  fetid,  the  patient  looks  ill  and  worn-out,  and 
the  hypogastric  dulness  points  to  the  presence  of  a  consider- 
able quantity  of  residual  urine,  the  case  must  be  regarded 
as  one  of  considerable  gravity.  The  employment  of  the 
catheter  for  the  first  time  under  these  conditions  is  likely  to 
be  attended  by  constitutional  disturbances,  sometimes  of 
severe  character.  The  examination  of  such  a  case  had  better 
not  be  completed  in  the  consulting-room — that  is  to  say,  you 
should  defer  drawing  off  the  urine  till  the  patient  goes  home. 
The  examination  should  be  completed  in  a  warm  room,  so 
that  the  patient  can  go  to  bed  immediately  afterwards, 
where  he  should  remain  for  two  or  three  days  in  any  case, 
and  for  a  longer  period  should  constitutional  disturbances 
set  in.  To  relieve  the  distended  bladder  and  then  allow  the 
patient  out  in  the  cold  is  injudicious  surgery.  In  hospital 
practice,  when  the  catheter  is  employed  in  a  case  of  this  kind 
in  the  out-patient  department,  the  man  should  be  at  once 


GENERAL  TREATMENT  OF  ENLARGED  PROSTATE     25 

admitted  to  bed.  If  the  quantity  of  residual  urine  be  large, 
only  about  half  should  be  drawn  off  on  first  introducing  the 
catheter.  The  quantity  removed  should  be  increased  at 
each  subsequent  introduction,  and  the  bladder  not  com- 
pletely emptied  for  two  or  three  days,  during  which  the 
patient  should  be  under  close  observation.  If  he  be  too 
infirm  or  nervous  to  pass  the  catheter  himself,  an  ex- 
perienced nurse  should  be  employed  for  this  purpose. 

Urinary  Fever  in  connection  with  Catheter  ism. 

In  an  advanced  case  of  prostatic  disease  of  this  kind  the 
urine,  even  when  clear  and  acid  on  the  first  introduction  of 
the  catheter,  generally  becomes  clouded,  and  eventually  am- 
moniacal,  in  the  course  of  a  few  days,  and  constitutional 
symptoms  supervene.  A  rigor  will  probably  occur,  or  even 
without  this  the  temperature  may  rise  to  1030  or  1040  F., 
profuse  perspiration  sets  in,  and,  the  normal  temperature 
being  reached,  the  fever  may  not  recur.  Sometimes  more 
than  one  attack  of  this  kind  occurs,  or  the  fever  may  be  of 
a  continuous  character  for  some  days,  gradually  subsiding  ; 
but  occasionally  the  patient  sinks  into  a  low  typhoid  state, 
with  dry,  furred  tongue,  feeble  pulse,  and  great  thirst  ;  and 
if  the  kidneys  are  much  affected,  uraemia,  followed  by  coma, 
may  set  in,  resulting  in  a  fatal  termination.  This  fever  is 
variously  termed  '  urinary,'  '  urethral,'  and  '  catheter,'  but  its 
exact  cause — whether  septic  or  neurotic — it  is  impossible 
with  our  present  knowledge  definitely  to  state.  Certainly  it 
occurs  under  the  strictest  antiseptic  precautions  and  with 
the  utmost  skill  in  passing  the  catheter.  The  general  treat- 
ment of  this  fever  is  similar  to  that  following  instrumenta- 
tion or  operation  for  stricture  of  the  urethra,  except  that, 
owing  to  the  advanced  age  and  debility  of  the  patient,  it 
must  be   more   sustaining,   stimulants   in  moderation   being 


26     GENERAL  TREATMENT  OF  ENLARGED  PROSTATE 

allowed.     When  the  urine  contains  pus,  the  local  treatment 
will  be  the  same  as  that  presently  to  be  described  for  cystitis. 

Cystitis. 

This,  as  we  have  already  seen,  is  a  common  complication 
of  enlarged  prostate,  so  that  we  must  always  be  prepared  to 
deal  with  it  in  its  earliest  stage.  When  the  urine  has  a 
tendency  to  become  cloudy,  and  gives  off  a  fishy,  offensive 
odour,  a  useful  drug  to  administer  is  boric  acid,  which  may 


Fig.  9. 

be  given  in  10-grain  doses  three  times  daily.  A  patient  of 
mine,  himself  a  medical  man,  who  for  years  has  been  de- 
pendent on  his  catheter,  informed  me  that  he  found  two  or 
three  large  doses  of  25  grains  each  more  effectual  in  bringing 
the  urine  back  to  its  normal  condition  than  repeated  small 
doses  ;  and  I  have  since  then  frequently  verified  this  ex- 
perience in  practice.  If  the  urine  becomes  decidedly 
alkaline,  the  boric  acid  should  be  combined  with  the 
benzoate  of  ammonia  in  10-grain  doses.  Urotropin  in 
doses  of  from  5  to  10  grains  three  times  daily  is  the  most 
efficient  drug  for  this  condition.  This  is  particularly 
effective  when  the  urine  contains  pus  and  mucus. 


GENERAL  TREATMENT  OF  ENLARGED  PROSTATE     27 

When  pus  forms,  the  bladder  must  be  washed  out  once  or 
twice  daily  with  disinfectants  or  astringent  lotions.  A 
4-ounce  indiarubber  bottle  fitted  with  nozzle  and  stopcock 
(Fig.  9)  is  the  most  convenient  apparatus  to  employ  for  the 
purpose.  It  should  be  completely  filled  with  the  lotion,  so 
as  to  avoid  the  introduction  of  air  into  the  bladder.  Not 
more  than  between  2  and  3  ounces  should  be  thrown  into 
the  bladder  at  one  time,  though  it  may  be  necessary  to 
repeat  this  process  several   times    before   the  fluid    returns 


Fig.  10. 


unaltered.  If,  however,  the  cystitis  be  severe,  not  more 
than  i  ounce  should  be  introduced,  as  the  bladder  walls  are 
under  such  circumstances  extremely  intolerant  of  tension. 
All  lotions  should  be  used  warmed  to  about  ioo°  F.  For 
cleansing  the  bladder  the  most  simple  and  useful  injections 
are  a  half-saturated  solution  of  boric  acid,  or  a  teaspoonful 
of  boro-glyceride  to  4  ounces  of  water.  Permanganate  of 
potash  solution,  commencing  with  1  in  5,000  and  gradually 
increasing  it  to  1  in  1,000,  and  perchloride  of  mercury,  1  in 
10,000,  make  excellent  injections.  But  our  sheet-anchor 
in  such  cases  is  nitrate  of  silver.  Commence  with  a  very 
weak  solution,  1  in  4,000,  gradually  increasing  the  strength 
to    1    in   750.     It  is  rarely  that  the   bladder  will  tolerate  a 


28      GENERAL  TREATMENT  OF  ENLARGED  PROSTATE 

stronger  solution.     I  have  found  solution  of  resorcin,  from 
3  to  5  per  cent.,  an  excellent  injection. 

When  there  is  great  pain  and  scalding  at  the  neck  of  the 
bladder  from  local  cystitis,  there  is  nothing  to  equal  daily 
'  installations '  of  a  strong  solution  of  nitrate  of  silver.  The 
urine  is  first  drawn  off  and  the  bladder  is  washed  out  with 
boric  lotion.  The  olivary  tip  of  a  Guyon's  catheter-syringe 
(Fig.  io)  is  then  passed  just  through  the  membranous 
portion  of  the  urethra,  and  a  drachm  of  the  solution, 
gradually  increased  from  i  to  3  per  cent.,  is  slowly  injected. 
This  trickles  back  into  the  bladder  and  is  allowed  to  remain 
there. 

Complete  Retention  of  Urine. 

This  is  liable  to  occur  suddenly  at  any  time  in  connection 
with  enlarged  prostate,  through  congestion  and  swelling  of 
that  organ  closing  up  the  already  narrowed  passage.  The 
congestion  may  be  due  to  cold,  sitting  on  a  wet  seat,  errors 
in  eating  and  drinking,  sexual  excesses,  an  attack  of  gout, 
or  injury  of  the  prostate  by  the  catheter.  Immediate  relief 
of  this  retention  is  imperative — by  means  of  the  catheter  if 
possible,  otherwise  by  operative  interference.  It  will  be  in- 
advisable to  waste  time  by  having  recourse  to  hot  baths  and 
opium,  as  in  the  case  of  retention  from  stricture,  for  the 
patient  being  old  and  the  muscular  power  of  the  bladder 
already  impaired,  any  delay  may  culminate  in  complete  and 
permanent  atony  of  the  bladder  from  overstretching  of  its 
muscles.  To  relieve  the  retention  catheters  of  various  kinds 
are  employed.  First,  a  vulcanized  indiarubber  catheter  should 
be  used.  It  is  astonishing  how  retention  may  occur  and  still 
little  or  no  resistance  be  offered  to  the  entrance  of  a  soft 
instrument  of  this  kind.  If  this  fail,  a  coudee  catheter,  and 
a  well-curved  one  terminating  in  a  coude,  should  be  tried 
in  succession.     If  still  unsuccessful,  a  well-curved  cylindrical 


GENERAL  TREATMENT  OF  ENLARGED  PROSTATE     29 

gum-catheter  without  a  stylet  should  be  employed.  This 
instrument  may  be  given  any  curve  at  pleasure  by  dipping 
it  in  hot  water,  bending  it  into  the  necessary  shape,  and  then 
plunging  it  into  cold  water,  when  it  retains  its  new  form.  If 
we  fail  with  this,  we  employ  the  same  catheter  mounted  on 
a  stylet.  As  soon  as  the  end  of  the  instrument  reaches  the 
obstruction  the  stylet  is  partly  withdrawn — a  manoeuvre 
which  has  the  effect  of  causing  the  end  of  the  catheter  to 
project  upwards  and  forwards,  thus  frequently  entering  the 
bladder.  Finally,  it  may  be  necessary  to  employ  an  ordinary 
silver  catheter,  or  one  with  a  longer  curve.  The  utmost 
gentleness  should  be  used,  force  of  any  kind  being  avoided, 
lest  a  false  passage  be  made,  or  haemorrhage  caused  by  injury 
to  the  prostate.  When  a  median  outgrowth  is  the  cause  of 
the  obstruction,  and  the  end  of  the  metal  catheter  fails  to 
ride  over  it,  the  point  should  be  directed  right  or  left  with  a 
view  to  hitting  off  the  channel  that  exists  on  either  side  of 
its  neck.  If  there  be  much  difficulty  in  introducing  a  flexible 
catheter,  it  should  be  tied  in  for  two  or  three  days,  but  a 
metal  instrument  should,  as  a  rule,  be  withdrawn.  If  we  fail 
to  introduce  any  kind  of  catheter,  temporary  relief  may  be 
given  by  suprapubic  aspiration,  after  which  in  the  course  of 
a  few  hours  a  catheter  may  pass  in  readily ;  should  this  fail, 
it  will  be  necessary  to  open  the  bladder  suprapubically  and 
drain  it  for  a  time. 

If  the  retention  occurs  in  an  early  stage  of  the  enlarge- 
ment, whilst  the  expulsive  power  of  the  bladder  is  still  unim- 
paired, it  is  possible  that  after  the  use  of  the  catheter  for  a 
few  days  the  bladder  may  return  to  its  normal  state  and 
habitual  cathetcrism  be  unnecessary.  But  when  the  disease 
is  far  advanced,  and  the  retention  has  existed  for  some  time, 
it  is  rare  for  the  bladder  to  retain  its  contractile  power 
sufficiently  to  overcome  the  prostatic  obstruction. 

An  attack  of  retention  is  almost   invariably  followed    by 


3o      GENERAL  TREATMENT  OF  ENLARGED  PROSTATE 

constitutional  symptoms,  so  that  the  patient  will  have  to 
remain  in  bed  for  several  days,  and  the  treatment  generally 
will  be  the  same  as  that  already  indicated  when  habitual 
catheterism  is  entered  upon. 

The  Pre-prostatic  Pouch. 

In  cases  of  enlarged  prostate  of  long  standing  we  may  find 
that  before  the  bladder  is  fairly  entered  a  pre-prostatic  pouch 
is  encountered — that  is,  a  pouch  lying  in  front  of  the  median 
outgrowth,  and  bounded  on  either  side  by  the  lateral  lobes 
of  the  prostate,  and  which  may  permit  the  beak  of  a  sound 
to  rotate  freely  within  it.  I  have  not  observed  any  reference 
to  this  pouch  in  the  text-books,  but  its  existence  is  of  great 
importance.  I  have  frequently  known  it  to  be  mistaken  for 
the  true  bladder  cavity.  Composed  of  the  dilated  prostatic 
urethra  and  that  portion  of  the  bladder  cavity  lying  in  front 
of  this  median  outgrowth,  it,  as  a  rule,  contains  urine  which 
is  drawn  off  by  the  catheter,  thus  giving  rise  to  the  impres- 
sion that  the  main  cavity  of  the  bladder  has  been  entered. 
Recently  I  was  called  in  consultation  to  see  a  case  of  this 
kind  in  which  the  medical  attendant  could  only  draw  off 
about  half  an  ounce  of  urine  each  time  he  introduced  the 
catheter,  but  without  relief  to  the  patient,  though  the  medical 
attendant  felt  sure  that  the  bladder  was  entered.  There 
was  great  distension  of  the  bladder,  felt  above  the  pubes, 
which  was  attributed  to  blood-clot,  as  the  patient  was 
subject  to  periodic  attacks  of  haemorrhage.  By  means  of  a 
well-curved  coudee  catheter  I  was  enabled  to  effect  an 
entrance  to  the  main  cavity  of  the  bladder  and  to  draw  off 
3  pints  of  blood-stained  urine,  but  in  doing  so  I  recognised 
a  large  pre-prostatic  pouch  from  which  the  urine  had 
previously  been  drawn. 

A  stone  may  form  in  this  position.  I  have  removed  several 
such  calculi,  generally  by  litholapaxy,  the  cavity  being  suffi- 


GENERAL  TREATMENT  OF  ENLARGED  PROSTATE    31 

ciently  large  to  permit  me  to  work  a  child's  lithotrite  in  it. 
I  have  also  known  calculi  lying  in  the  main  cavity  of  the 
bladder  missed  through  the  surgeon  mistaking  this  pouch  for 
the  bladder  proper. 

Haemorrhage  from  the  Prostate. 

Haemorrhage  rarely  occurs  in  the  early  stages  of  enlarge- 
ment of  the  prostate,  but  when  the  disorder  is  well  advanced 
this  is  always  liable  to  take  place  from  various  causes.  The 
bleeding  may  arise  from  the  mucous  membrane  of  the  bladder 
or  from  the  prostate.  During  the  early  days  after  entry  on 
the  habitual  use  of  the  catheter  it  is  liable  to  occur  from  the 
former  source,  when  there  was  much  distension  from  residual 
urine  previously,  due  to  rupture  of  the  vessels  from  their  being 
deprived  of  their  accustomed  support.  As  a  rule,  the  haemor- 
rhage is  trifling,  merely  discolouring  the  urine,  without  the 
presence  of  clots,  and  requires  no  particular  treatment, 
the  symptoms  gradually  passing  off.  Then,  there  may  be 
haemorrhage  as  the  result  of  congestion  of  the  prostate  after 
exercise  or  exposure  to  wet  and  cold.  This  is  seldom  severe, 
and  also  passes  off  with  rest.  In  advanced  stages  of  the 
disorder  there  is  frequently  a  varicose  condition  of  the  veins 
on  the  surface  of  the  prostate,  and  some  haemorrhage  may 
occur  from  rupture  of  these.  The  bleeding  may  be  so  profuse 
as  to  distend  the  bladder.  On  many  occasions  I  have  had 
to  open  the  bladder  suprapubically  to  turn  out  an  enormous 
clot  filling  its  cavity.  But  the  most  frequent  cause  of  haemor- 
rhage; is  injury  of  the  prostate  by  careless  or  unskilful  use  of 
the  catheter,  or  from  difficulty  in  passing  the  instrument. 
As  a  rule,  the  blood  is  mixed  with  the  urine ;  but  if  the  injury 
be  on  the  prostatic  urethra,  or  oil  the  anterior  surface  of  an 
enlarged  median  outgrowth  almost  blocking  the  orifice,  the 
blood  may  flow  away  quite  pure  from  the  urethra. 

The  treatment   consists  in   perfect    rest    in    bed    and    the 


administration  of  opium.  The  usual  styptic  drugs  are  of 
little  or  no  avail.  The  blood-clots  may  be  allowed  to  dissolve 
and  come  away  with  the  urine.  Washing  them  out  through 
a  full-sized  catheter  with  a  large  eye  may  be  tried,  but  care 
should  be  taken  that  this  does  not  induce  further  haemorrhage. 
When,  owing  to  difficulty  in  passing  the  catheter,  bleeding 
occurs  on  each  introduction,  it  is  better  to  tie  in  a  good-sized 
coudee  catheter  for  a  few  days.  If  it  gets  clogged  with  clot, 
this  may  be  displaced  by  gently  injecting  a  little  boric  lotion 
from  an  indiarubber  bottle. 

Frequent  haemorrhage  attended  by  much  pain  after 
exercise  in  prostatic  patients  should  always  give  rise  to 
the  suspicion  of  the  presence  of  stone.  If  a  calculus  lie  in 
a  saccule  projecting  out  from  the  base  of  the  bladder,  there 
may  be  intense  agony  during  defecation  if  constipation  exist, 
and  the  urine  will  generally  be  blood-stained  afterwards.  I 
have  met  with  two  cases  of  this  kind  in  practice — one  in 
which  the  symptoms  were  completely  relieved  after  the 
stone  was  removed  suprapubically,  and  the  cause  of  the 
other  was  discovered  only  after  death. 

Orchitis  is  common  in  connection  with  enlarged  prostate, 
as  a  result  of  catheterism  or  independently  of  this ;  and  ex- 
cessive tenderness  of  one  or  both  testicles  is  sometimes  found, 
quite  apart  from  any  inflammatory  state  of  the  organs. 
Urethritis  and  balanitis  may  occur,  particularly  in  patients 
suffering  from  diabetes. 


LECTURE  III 

THE  AUTHORS  OPERATION  OF   TOTAL  ENUCLEATION  OF 
THE  ENLARGED  PROSTATE  IN  ITS  CAPSULE 

In  November,  1900,  I  delivered  a  series  of  lectures  in  this 
College,  in  which  I  endeavoured  to  give  a  practical  summary 
of  our  knowledge,  as  it  then  existed,  of  the  disease  generally 
known  as  '  hypertrophy  of  the  prostate,'  describing  its 
pathology,  symptoms,  diagnosis,  and  various  methods  of 
treatment. 

It  was  then  pointed  out  that  there  is,  perhaps,  no  other 
disease  in  the  whole  range  of  surgery  for  which  so  many  and 
diverse  modes  of  treatment  have  been  advocated — a  fact  in 
itself  suggestive  of  the  unsatisfactory  nature  of  most,  if  not 
all  of  them,  so  that  at  the  time  catheterism  pure  and  simple, 
with  all  its  disadvantages  and  dangers,  reigned  supreme  in 
the  practice  of  most  surgeons  as  the  least  objectionable 
of  all. 

From  time  to  time  various  procedures  had  been  proposed 
and  practised  with  a  view  to  an  attempt  at  radical  cure  of 
the  disease,  and  a  whole  lecture  was  given  up  to  a  detailed 
description  of  the  most  important  <>f  them.  [This  Lecture, 
which  appeared  in  the  first  and  second  editions  of  this  work, 
is  now  omitted,  as  the  surgical  procedures  referred  to  have 
since  been  practically  abandoned,  ami  are  now  merely  of 
historical  interest.] 

Most  prominent  amongst  them  maybe  mentioned  partial 

33 


34     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

prostatectomy  (whether  by  the  urethral,  perineal,  or  supra- 
pubic route),  castration,  vasectomy,  and  Bottini's  operation, 
which  consisted  in  an  attempt  to  burn  away  by  the  electric 
cautery  the  so-called  '  middle  '  lobe  of  the  prostate. 

Each  of  these  procedures  enjoyed  a  temporary  though 
transient  notoriety.  I  ventured  to  hold  that  partial  pros- 
tatectomy by  the  suprapubic  route,  first  performed  by 
Belfield  of  America,  but  best  known  in  this  country  in 
connection  with  the  name  of  McGill,  who  brought  it 
prominently  before  the  profession  in  1888,  was  the  most 
practical  attempt  at  a  rational  method  of  dealing  with  the 
obstruction  caused  by  the  enlarged  prostate. 

The  operation  consisted  in  opening  the  bladder  supra- 
pubically  and  removing  the  prominent  portions  of  the 
prostate  in  that  viscus,  or  as  much  of  it  as  possible,  by 
means  of  scissors,  forceps,  and  scoops  of  kinds.  I  myself 
had  performed  this  operation  on  several  occasions  with 
some  measure  of  success.  But  apart  from  the  high 
mortality  attending  the  procedure  it  possessed  the  dis- 
advantage that,  though  frequently  followed  by  the  sub- 
sidence of  the  most  prominent  symptoms,  temporarily  at 
least,  and  rendering  the  employment  of  the  catheter  more 
easy,  in  a  very  large  proportion  of  cases  the  bladder  failed  to 
regain  its  power  of  expelling  the  urine.  This  was  due  to 
the  fact  that  the  outgrowth  in  the  bladder  is,  as  a  rule,  not 
the  only  or,  indeed,  the  chief  cause  of  the  obstruction,  as 
was  imagined,  which  is  mainly  due  to  the  lateral  pressure  on 
the  urethra  by  the  enlarged  prostatic  lobes.  Indeed,  when 
once  the  bladder  had  completely  lost  its  expulsive  power — 
that  is  to  say,  when  the  whole  of  the  urine  had  to  be  drawn 
off  by  the  catheter — McGill's  operation  was  practically  in- 
capable of  restoring  that  power.  Add  to  this  the  fact  that, 
as  only  the  prominent  portions  of  the  prostate  in  the  bladder 
were  removed,  there  was  no  immunity  against  recurrent  out- 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE    35 

growth  or  general  enlargement  of  the  gland,  and  we  realize 
in  what  a  very  limited  sense  this  operation  could  be  regarded 
as  radical.  Owing  to  these  considerations  the  operation, 
after  enjoying  a  temporary  and  fitful  notoriety  for  a  few 
years,  may  be  said  to  have  died  out  of  surgical  practice.  It 
was  replaced,  first  by  castration  and  later  by  vasectomy, 
which  was  practised  extensively  during  the  closing  years  of 
last  century.  Experience  has  shown  that  both  these  pro- 
cedures were  practically  useless,  and  that  the  former  was 
not  only  attended  by  a  very  serious  rate  of  mortality,  but 
that  it  was  frequently  followed  by  grave  disturbances  of  the 
mental  balance.  They  no  longer  hold  a  place  in  practical 
surgery. 

Shortly  after  these  lectures  were  delivered,  on  December  1, 
1900,  I  performed  a  new,  and  what  seemed  at  first  sight  a 
very  formidable,  operation  for  radical  cure  of  the  disease — 
namely,  total  enucleation  of  the  enlarged  prostate.  In  a 
lecture  delivered  at  the  College  in  June,  1901, 1  gave  full  details 
of  this  and  three  further  cases  in  which  I  had  undertaken 
the  operation,  in  all  four,  with  complete  success.  Two  of  the 
patients  were  shown  at  the  lecture  in  perfect  health,  able  to 
retain  and  pass  their  urine  as  well  as  they  ever  did,  though 
previously  completely  dependent  on  the  catheter.  The 
lecture  was  published  in  July,  1901,"  and  the  operation  was 
thus  submitted  for  the  consideration  of  the  profession  at 
large. 

The  complete  success  that  followed  these  operations 
entirely  revolutionized  my  views  regarding  the  treatment  of 
this  widespread  and  painful  malady,  and  opened  up  a  new 
era  in  this  branch  of  surgery.  Since  then  I  have  from  time 
to  time  published  lectures  and  papers  on  several  series  of 
cases  of  my  operation.  In  this  manner  full  details  of  in\ 
tirst  2<><>  <ascs  have  been  plane!  before  the  profession. 
*  British  Medicat Journal,  July  20,  [901. 

J— 2 


36     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

Having  now  performed  the  operation  in  more  than  300  cases, 
I  propose  in  this  lecture  to  review  its  present  position,  giving 
the  latest  details  of  the  procedure,  and  describing  the 
anatomical  and  pathological  considerations  that  render  it 
practicable. 

A  careful  examination  of  the  specimens  removed  in  these 
operations  throws  an  entirely  new  light  on  the  anatomy  of 
the  prostate  and  its  relations  to  the  surrounding  structures, 
and  shows  that  the  descriptions  contained  in  the  anatomical 
text-books  generally  are  incomplete  and  erroneous  in  treating 
that  organ  as  a  single  body  with  a  canal  tunnelled  through 
it  in  the  form  of  the  prostatic  urethra. 

The  prostate  is  in  reality  composed  of  twin  organs,  of 
apparently  purely  sexual  function,  which,  in  some  of  the 
lower  animals,  remain  distinct  and  separate  throughout  life, 
as  they  exist  in  the  human  male  during  the  first  four  months 
of  foetal  existence.  After  that  period,  in  the  human  foetus, 
they  approach  each  other,  and  their  inner  aspects  become 
agglutinated  together,  except  along  the  course  of  the  urethra, 
which  they  envelop  in  their  embrace. 

These  two  glandular  organs,  which  constitute  the  lateral 
lobes  of  the  prostate,  though  welded  together,  as  it  were,  to 
form  one  mass,  remain,  so  far  as  their  secreting  substance 
and  functions  are  concerned,  practically  as  distinct  as  the 
testes,  their  respective  gland-ducts  opening  into  the  urethra 
on  either  side  of  the  verumontanum. 

Each  of  these  two  glandular  bodies,  or  prostates,  is 
enveloped  by  a  strong,  fibro-muscular  capsule ;  and  it  is 
these  capsules — less  those  portions  of  them  that  dip  inwards, 
covering  the  opposing  aspects  of  the  glandular  bodies  or 
lobes,  and  thus  disappearing  from  view,  being  embedded  in 
the  substance  of  the  prostatic  mass — that  constitute  the  true 
capsule  of  the  prostate  regarded  as  a  whole.  This  capsule 
extends  over  the  entire  organ  except  along  the  anterior  and 


OPERATIOX  OF  TOTAL  ENUCLEATION  OF  PROSTATE     37 

posterior  commissures  or  bridges  of  tissue  that  unite  the 
lateral  lobes  in  front  of  and  behind  the  urethra,  thus  filling 
in  the  gaps  between  them.  This  true  capsule  is  intimately 
connected  with  the  prostatic  mass,  and  incapable  of  being 
removed  from  it  even  by  dissection. 

The  urethra,  accompanied  by  its  surrounding  structures — 
viz.,  its  longitudinal  and  circular  coats  of  muscles  continued 
downwards  from  the  bladder,  its  vessels  and  nerves — passes 
downwards  and  forwards  between,  and  is  embraced  by,  the 
inner  aspects  of  the  two  glands  or  lobes. 

The  ejaculatory  ducts  enter  the  prostatic  mass  close 
together  in  an  interlobular  depression  at  the  posterior  part 
of  its  upper  aspect,  each  duct  coursing  along  the  inner 
surface  of  the  corresponding  lobe.  They  do  not  penetrate 
the  capsules  of  the  lobes,  but  pass  forwards  in  the  interlobular 
tissue  to  open  into  the  urethra. 

The  prostate,  thus  constituted  and  enveloped  by  its  true 
capsule,  is  further  encased  in  a  second  capsule  or  sheath, 
formed  mainly  by  the  recto-vesical  fascia,  numerous  con- 
necting bands,  however,  passing  between  the  two.  The 
nomenclature  here  adopted  is  that  suggested  by  the  late  Sir 
Henry  Thompson  in  his  work, '  The  Diseases  of  the  Prostate,' 
and  is  both  scientific  and  practical.  Embedded  in  the  outer 
capsule,  or  sheath,  lies  the  prostatic  plexus  of  veins,  most 
marked  in  front  and  on  the  sides  of  the  prostate.  This 
diagram  (Fig.  11)  shows  the  structure  of  the  prostate  and 
surrounding  parts. 

There  is  nothing  that  1  can  call  to  mind  that  illustrates 
more  simply  and  forcibly  the  composition  of  the  prostate 
and  its  coverings  than  an  orange.  If  we  imagine  the  edible 
portion  of  an  orange  composed  of  two  segments  only  instead 
of  several,  with  the  septum  between  them  placed  vertically, 
we  have  a  rough  and  homely  illustration  of  the  formation  of 
the   prostate.     The  strong    fibrous  tissue  which  covers   the 


38     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

segments  of  the  orange,  and  which  is  intimately  connected 
with  the  pulp,  represents  the  true  capsule  of  the  prostate,  the 
two  segments  or  halves  of  the  orange  being  represented  by 
the  two  lobes.  Further,  the  rind  of  the  orange  outside  all 
represents  the  outer  capsule  or  prostatic  sheath  formed  by 
the  recto-vesical  fascia. 

And  here  let  me  remark  that  in  the  operation  that  I  shall 
presently  set  forth,  it  is  this  inner  or  true  capsule  as  above 


Anterior  Commissuiz 


LllbLoU 


Right  Lobe 


Urethra. 


Plane  0/ 
^tSaration 


tein  of       „ 

"     Prostatic  Pittas 

£kea.tk 


—  dijbsale 


-  Piaae  of 

Separation 


J.H.T.K. 


Eiatolatory  Duels 


Fig.  ii. — Diagrammatic  View  of  Coronal  Section  of  Prostate 
and  Surrounding  Sheath. 


described  that  is  removed,  the  outer  capsule  or  sheath  being 
left  behind,  thus  preventing  infiltration  of  urine  into  the 
cellular  tissues  of  the  pelvis.  The  text-books,  as  a  rule, 
draw  no  distinction  between  the  two  separate  coverings  of 
the  prostate,  treating  them  both  combined,  or  the  outer  one 
only,  as  '  the  capsule.'  To  persons  brought  up  in  this  school 
of  thought  and  teaching  my  operation  must  at  first  sight 
necessarily  have  appeared  impossible. 

In  most,  if  not  in  all,  cases  of  enlargement  of  the  prostate 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE    39 

of  declining  life  (cancer  being  excluded)  the  overgrowth  is 
adenomatous  in  character,  numerous  encapsuled  adenomatous 
tumours  being  found  embedded  within  the  substance  of  the 
lobes,  and  frequently  protruding  on  their  surfaces.  They 
sometimes  assume  the  form  of  polypoid  outgrowths  (Fig.  1), 


RXo^t  l-0(* 


Bladder 


.Ltft  Lobe, 
--Shextk. 


Ttia/yvUT  Liqzintnt 


J.W.TK 


Vrethi 


Fig.  [2.    Diaqrammatic  View  of  Horizontal  Section  ok 
Enlarged  Prostate  and  Bladder. 


which,  however,  are  invariably  enclosed  within  the  true  capsule, 

which  is  pushed  before  them. 

As  the  lobes  enlarge  they  bulge  out  and  have  a  tendency, 
ea<  h  enclosed  within  its  own  capsule,  to  become  more  defined 
and  isolated,  thus  recalling  their  separate  existence  in  early 
foetal  life.     They  become  more  loosely  attached  along   their 


40     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

commissures  (particularly  the  anterior  one),  which  in  the 
normal  prostate  unite  them  in  front  of,  and  behind,  the 
urethra.  And  in  the  course  of  this  change  the  urethra,  with 
its  accompanying  structures,  is  loosened  from  its  close  attach- 
ment to  the  inner  surfaces  of  the  lobes,  particularly  in  front 
of  the  verumontanum,  thus  facilitating  its  being  detached  and 
left  behind  in  the  removal  of  the  prostate,  as  will  presently 
appear. 

In  the  earlier  stages  of  the  adenomatous  overgrowth  the 
enlargement  is  probably  entirely  extravesical.  Its  expansion 
in  this  position  is,  however,  limited,  particularly  by  the 
triangular  ligament  below.  As  the  enlargement  progresses 
it  advances  in  the  direction  of  least  resistance — namely, 
upwards  into  the  bladder.  The  sheath  at  the  superior  aspect 
of  the  prostate  is  incomplete  around  the  urethra.  As  the 
enlargement  proceeds  the  prostate  gradually  insinuates  itself 
through  this  opening  in  the  sheath  into  the  bladder  (Fig.  12), 
and  the  inner  layer  of  the  muscle  of  the  bladder  becoming 
thinner  and  thinner  from  gradual  pressure  of  the  outgrowth 
the  prostate  in  this  direction  is  eventually  merely  covered  by 
mucous  membrane. 

In  most  of  the  specimens  of  enlarged  prostate  removed  by 
me  in  this  operation  a  well-defined  circular  groove  is  noticeable 
at  the  junction  of  the  intra-  and  extra- vesical  portions.  This  is 
caused  by  the  constriction  of  the  growth  by  the  sharply- 
defined  edges  of  the  sheath,  which  become  sickle-shaped  on 
either  side  as  the  prostate  shoulders  its  way  into  the  bladder, 
and  by  the  sphincter  muscle.  The  shape  of  the  outgrowth 
of  the  prostate  in  the  bladder  appears  to  be  mainly  influenced 
by  the  conformation  of  the  sheath  superiorly,  and,  as  pointed 
out  by  Mr.  Thomson  Walker,  by  the  two  strong,  muscular 
bands  found  in  the  inner  layer  of  the  bladder  muscle,  which 
are  continued  downwards  from  the  ureters,  and,  converging, 
pass  into  the  floor  of  the  urethra.    Sometimes  this  outgrowth 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE    41 

assumes  the  form  commonly  known  as  a  '  middle '  lobe, 
which,  as  can  be  seen  from  the  specimens,  is  not  a  middle 
lobe  at  all — there  being  no  such  structure  in  the  normal 
prostate,  as  pointed  out  by  Sir  Henry  Thompson  more  than 
forty  years  ago — but  an  outgrowth  from  one,  or  both,  of  the 
lateral  lobes.  More  frequently,  however,  there  is  a  protrusion 
of  each  lateral  lobe  into  the  bladder,  and  this  may  advance 
to  such  an  extent  that  one  half,  or  even  more,  of  the  enlarged 
prostate  may  lie  in  this  viscus. 

These,  briefly,  are  the  anatomical  and  pathological  con- 
siderations on  which  my  operation  is  based — a  comprehension 
of  which  is  necessary  in  order  to  follow  me  in  my  description 
of  the  details  of  the  procedure.  They  are  fully  described  in 
a  very  able  paper  recently  communicated  to  the  Royal 
Medical  and  Chirurgical  Society  by  Mr.  J.  W.  Thomson 
Walker.* 

My  ideal  operation  at  the  outset  consisted  in  enucleating 
the  enlarged  prostate  entire  in  its  capsule  out  of  the  encasing 
sheath,  leaving  the  urethra  with  its  accompanying  structures 
behind.  But,  as  will  subsequently  appear,  I  discovered  at 
an  early  stage  in  the  history  of  the  operation  that  the 
prostatic  urethra  might  be  torn,  or  even  partially  or  entirely 
removed,  with  equally  good  eventual  results. 

The  Operation. 

Before  performing  the  operation  the  bladder  is  thoroughly 
washed  out  with  ;m  antiseptic  Lotion,  as  in  this  disease  the 
urine  is  almost  invariably  foul.  The  catheter  employed  for 
this  purpose  should  be  made  of  rather  stiff  gum-elastic,  and 
be  "I  the  largest  size  that  the  urethra  will  readily  admit. 

Suprapubic  cystotomy  is  now  performed.  After  washing 
out  the  bladder  the  catheter  is  Kit  in  situ,  and  the  viscus  is 
distended  with  boracic  lotion.  The  nozzle  of  the  large 
*  British  Medical Journal ',  July  2,  1904. 


42     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

syringe  employed  for  this  purpose,  and  which  is  filled  with 
lotion,  is  inserted  in  the  end  of  the  catheter,  thus  acting  as 
a  plug  to  prevent  leakage  from  the  bladder,  and  the  syringe 
being  ready  to  further  distend  the  bladder  with  fluid,  if  neces- 
sary, as  the  operation  proceeds.  An  incision,  varying  in  length 
from  2 \  to  3J  inches,  according  to  the  stoutness  of  the  patient 
and  the  size  of  the  prostate,  is  made  in  the  median  line  of  the 
abdomen,  its  lower  end  reaching  to  the  level  of  the  pubic 
arch.  This  incision  is  rapidly  carried  down  through,  or 
between,  the  recti  muscles  till  the  prevesical  space  is  opened. 
Any  bleeding  vessels  having  been  clamped  by  catch-forceps, 
the  forefinger  is  introduced  into  the  lower  angle  of  the 
wound,  and  the  prevesical  fat  scraped  upwards  off  the  bladder 
by  the  finger-nail  for  the  whole  length  of  the  wound.  The 
peritoneum,  which  should  not  be  seen,  is  thus  pushed 
upwards  out  of  harm's  way,  and  the  bladder  appears  deeply 
in  the  wound,  quite  tense,  glistening,  and  of  a  pale  white 
colour,  with  large  and  tortuous  veins  coursing  in  its  substance. 
Selecting  an  area  devoid  of  veins,  the  point  of  the  scalpel  is 
plunged  boldly  into  the  bladder,  and  an  incision  about  an 
inch  long  made  in  the  vertical  direction  towards  the  sym- 
physis. The  wound  in  the  bladder  can  be  subsequently 
enlarged  if  necessary  ;  and  this  is  best  effected — as  being 
attended  by  least  bleeding — by  separating  two  fingers  placed 
in  the  wound,  and  thus  tearing  the  bladder  wall  to  the 
required  extent.  On  withdrawal  of  the  scalpel  the  forefinger 
is  introduced  into  the  bladder  as  the  lotion  rushes  out  through 
the  wound,  and  a  general  survey  of  the  interior  of  the  viscus 
is  made.  Should  calculi  be  present  they  are  at  once  removed 
by  forceps  or  scoop. 

The  forefinger  of  the  other  hand  is  next  introduced  into 
the  rectum  to  render  the  prostate  prominent  in  the  bladder, 
and  to  keep  it  steady  during  the  manipulation  by  the  first 
hand.     The  mucous   membrane   over   the    most    prominent 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE    43 

portion  of  one  lateral  lobe  (Fig.  12),  or  over  the  so-called 
'  middle  '  lobe,  if  there  be  but  one  prominence,  is  scored 
through  by  the  sharpened  finger-nail,  and  gradually  detached 
by  it  from  the  prominent  portion  of  the  prostate  in  the 
bladder. 

As  I  have  already  explained,  this  portion  of  the  enlarged 
prostate  is  covered  merely  by  mucous  membrane,  so  that 
when  this  is  scraped  through  and  detached  the  true  capsule 
of  the  prostate  is  at  once  reached. 

Keeping  the  finger's  point  in  close  contact  with  the  capsule, 
the  enucleation  of  the  prostate  out  of  the  enveloping  sheath 
outside  the  bladder  is  proceeded  with  by  insinuating  the 
finger-tip  in  succession  behind,  outside,  and  in  front  of  one 
lateral  lobe,  thus  separating  the  capsule  from  the  sheath. 
The  finger  is  then  swept  in  a  circular  fashion  from  without 
inwards,  in  front  of  and  to  the  inner  side  of  the  lobe,  detach- 
ing this  from  the  urethra,  which  is  felt  covering  the  catheter, 
and  pushed  forwards  towards  the  symphysis  between  the 
lateral  lobes  which  will,  as  a  rule,  have  separated  along  their 
anterior  commissure  in  the  course  of  the  manipulations. 
The  other  lobe  is  attacked  and  treated  in  the  same  manner. 
The  finger  is  next  pushed  well  downwards  behind  the 
prostate  and  the  inferior  surface  of  the  gland  is  peeled  off 
the  triangular  ligament.  When  the  prostate  is  felt  fret.' 
within  its  sheath  and  separated  from  the  urethra,  with  the 
finger  in  the  rectum,  aided  by  that  in  the  bladder,  it  is 
pushed  into  the  bladder  through  the  opening  in  the  mucous 
membrane,  which,  during  the  manipulations,  will  have  become 
considerably  enlarged. 

The  prostate,  which  now  lies  free  in  the  bladder,  is  with- 
drawn by  strong  forceps  through  the  suprapubic  wound. 
And  lure  I  may  remark  that  it  is  astonishing  through  what 
a  comparatively  small  suprapubic  wound  a  very  large  prostate 
can  be  delivered,  owing  to  the  elasticity  and  compressibility 


44     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

between  the  blades  of  the  forceps  of  the  adenomatous 
growth.  Sometimes  the  lobes  become  detached  along 
both  anterior  and  posterior  commissures  and  come  away 
separately. 

The  question  now  arises,  What  becomes  of  the  ejaculatory 
ducts  in  the  course  of  this  operation  ? 

When  the  lobes  come  away  separately  they  are  probably 
left  behind  uninjured,  attached  to  the  urethra.  When  the 
prostate  comes  away  as  a  whole,  they  may  be  torn  across,  or 
pulled  out  of  the  gland,  a  matter  of  trifling  importance  at  an 
age  when,  as  a  rule,  the  reproductive  powers  are  lost.  But, 
as  will  subsequently  appear,  in  the  vast  majority  of  my  later 
operations,  the  distorted  portion  of  the  urethra  behind  the 
verumontanum  has  been  removed  with  the  prostate,  the 
urethra  being  severed  at  the  position  at  which  the  ejaculatory 
ducts  enter  it,  the  ducts  as  a  rule  remaining  adherent  to  the 
portion  of  the  prostatic  urethra  that  is  left  behind. 

Almost  from  the  commencement  I  have  abandoned  the 
employment  of  any  cutting  instrument  for  incising  the 
mucous  membrane,  finding  the  finger-nail  alone  most  con- 
venient and  expeditious.  Besides,  when  scissors  or  scalpel 
are  employed  there  is  danger  of  entering  the  capsule,  and  the 
guiding-line  being  thus  lost,  the  finger  flounders  about  inside, 
enucleating  isolated  adenomatous  tumours  instead  of  the 
whole  organ  in  its  capsule. 

There  is,  as  a  rule,  very  little  bleeding  from  the  operation. 
It  is  astonishing  the  rapidity  with  which  the  cavity  left  by 
the  removal  of  the  prostate  practically  disappears,  owing  to 
the  inherent  elasticity  of  the  sheath,  the  contractility  of 
the  surrounding  muscles,  and  the  pressure  of  the  pelvic 
structures  generally.  The  contraction  that  takes  place  some- 
what resembles  that  of  the  womb  in  parturition,  and  no 
doubt  has  a  similar  influence  in  arresting  haemorrhage.  The 
contractility    of    the    cavity   will    be    greatly    facilitated    by 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE    45 

pressing  its  opposing  surfaces  together  by  the  points  of  the 
fingers  in  the  bladder  and  rectum  respectively.  Irrigation  of 
the  bladder  by  hot  lotion  through  the  catheter  and  out  by 
the  suprapubic  wound  will  also  help  to  check  bleeding  and 
remove  clots  from  the  bladder.  But  I  find  that  if  continued 
for  more  than  a  minute  or  two  it  increases  the  bleeding 
instead  of  diminishing  it. 

A  stout  drainage-tube  is  introduced  into  the  bladder 
through  the  suprapubic  wound  and  retained  there  by  a 
suture  for  four  or  five  days  ;  the  abdominal  wound  is 
brought  together  by  sutures,  and  the  patient's  abdomen 
swathed  in  absorbent  dressings.  But  the  toilet  of  the  wound 
and  the  after-treatment  are  of  such  importance  that  a 
separate  lecture  will  be  devoted  thereto.  So  I  will  conclude 
by  giving  details  of  a  few  illustrative  cases,  showing  what 
may  be  accomplished  by  this  operation.  And  in  the  first 
instance  let  me  introduce  the  first  two  patients  on  whom  I 
performed  this  operation  some  five  years  ago.  They  have 
come  at  my  request,  so  that  you  may  interrogate  and 
examine  them  yourselves,  and  bear  testimony  to  the  per- 
manence of  the  cure.  They  are  both,  indeed,  in  excellent 
health,  untroubled  by  any  urinary  symptom,  and  they  will 
tell  you  that  they  regained  their  sexual  power  after  having 
lost  it  temporarily  before  operation,  through  the  pain  and 
debility  attendant  on  the  malady. 

Illustrative  Cases. 

Case  \.    J.  T ,  aged  seventy-one,  admitted  to  St.  Peter's  Hospital, 

November  21,  1900,  with  prostatic  symptoms  of  several  years1  standing. 
Double  vasei  tomy  had  been  performed  by  me  in  January,  1000,  but  with 
no  amelioration  of  the  symptoms.  Catheter  employed  for  one  yeai  ; 
entirely  dependent  thereon,  nine  months  ;  prostate,  fter  rectum,  much 
enlarged,  bilobed,  smooth,  -<>i"t.  movable.  Cystoscopic  examination  on 
November  28  revealed  ;i  bilateral  prominence  of  the  prostate  in  the 
bladder.  Total  enucleation  of  the  prostate  was  performed  by  me 
1  'c  ember  1,  1900,  in  the  manner  just  described,  the  lobes  1  oming  away 


46     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

separately  and  the  urethra  being  left  behind.  Considerable  bleeding  at 
first,  but  this  was  quickly  arrested  by  irrigation  with  hot  hazeline  solution. 
No  vessels  were  ligatured.  On  December  13  patient  passed  12  ounces  of 
urine  per  icretliram,  and  subsequently  none  passed  by  the  wound,  which 
had  completely  healed  by  December  2 1 .  The  prostate  weighed  2 \  ounces. 
This  patient,  as  you  see,  now  aged  seventy-six,  five  years  after  operation, 
is  in  perfect  health,  able  to  pass  and  retain  his  urine,  which  is  normal, 
as  well  as  he  ever  did. 

Case  2. — Gentleman,  aged  sixty-seven,  consulted  me  for  prostatic 
symptoms  of  five  years'  duration.  Catheter  employed  for  three  and  a 
half  years  ;  entirely  dependent  thereon,  six  months.  Urine  thick  with  pus 
and  very -offensive. 

On  March  30,  1901,  I  enucleated  the  prostate,  the  lobes,  as  in  the 
previous  case,  coming  away  separately,  and  the  urethra  being  left  behind. 
Recovery  was  uninterrupted  and  complete.  Left  the  surgical  home  May  2  ; 
able  to  pass  and  retain  his  urine  normally.  He  is  now,  as  you  see,  four 
years  and  eight  months  after  operation,  in  excellent  health,  and  he  will 
tell  you  that  he  can  retain  and  pass  his  urine  naturally  as  well  as  he  ever 
did.  He  will  further  tell  you  that  his  sexual  power,  which  was  com- 
pletely lost  for  two  years  before  operation,  was  regained,  and  that  he  has 
emissions  of  semen,  showing  that  the  ejaculatory  ducts  were  unharmed 
in  the  operation.     The  prostate  weighed  2|  ounces. 

Case  4.  —  Gentleman,  aged  sixty-two,  sent  by  Dr.  W.  Douglas, 
Newbury.  Prostatic  symptoms,  one  year  ;  catheter  employed,  six 
months,  but  patient  passed  some  urine  naturally  ;  acute  cystitis,  with 
great  frequency  of  micturition — half-hourly  by  day  and  night ;  much 
pain  and  frequent  stoppage  of  urine  ;  residual  urine,  8  ounces,  con- 
tained much  pus  ;  prostate  greatly  enlarged  per  Tectum,  bilobed,  soft, 
movable.  Cystoscopic  examination  revealed  bilateral  prominence  of 
the  prostate  in  the  bladder  with  a  pedunculated  outgrowth,  which  acted 
as  a  ball-valve  to  the  urethra. 

On  June  7,  1901,  Mr.  H.  F rankling  assisting,  I  enucleated  the  prostate 
(Fig.  13)  entire  in  its  capsule,  leaving  the  urethra  behind.  Patient 
passed  several  ounces  of  urine  per  urethram,]xine  12,  and  on  June  16  the 
wound  was  closed.  Before  leaving  the  surgical  home  he  was  seen  by 
Dr.  J.  Farquharson,  M.P.,  and  others,  in  good  health,  able  to  pass  and 
retain  his  urine  normally.  I  have  seen  him  on  several  occasions  since 
then  in  perfect  health,  and  pursuing  his  ordinary  avocation  with  vigour. 
On  December  31,  1905,  four  a  half  years  after  operation,  he  writes: 
'  From  the  day  I  left  the  home  up  to  the  present  time  I  have  never 
suffered  the  slightest  pain  or  inconvenience  in  any  way,  and  I  feel  now 
ten  years  younger  than  when  I  first,  so  fortunately  for  me,  met  you.' 
The  prostate  (Fig.  13),  which  weighed  2j  ounces,  presents  a  well-marked 
pedunculated  outgrowth  in  the  bladder. 


OPERATIOX  OF  TOTAL  ENUCLEATION  OF  PROSTATE     47 

Case  9.— C.  I) ,  aged  fifty-eight,  suffering  from  prostatic  symptoms 

for  seven  years,  complicated  by  organic  stricture  of  the  urethra.  Catheter 
employed  five  years;  entirely  dependent  thereon  for  about  a  month; 
much  pain,  difficulty  with  catheter,  and  bleeding  ;  urine  contained  pus  ; 
prostate  much  enlarged,  rounded,  bilobed,  smooth,  dense,  elastic, 
movable.     Cystoscope  revealed  bilateral  outgrowth  in  bladder. 

On  January  15,  1902,  at  St.  Peter's  Hospital,  I  enucleated  the 
prostate  entire,  the  lobes  opening  along  the  anterior  commissure,  and  the 
urethra  being  left  behind  ;  very  little  bleeding  or  shock.     Some  urine 


Fig.  13. — Prostate,  weighing  z\  Ounces,  removed  from  Patient 
aged  Sixty-two  (Case  4).    Actual  Si     , 

Shows  pedunculated  outgrowth  in  bladder.     The  groove  A,  B  radical 
position  in  which  urethra  lay. 


passed  per  urethram  January  21 ,  and  wound  was  firmly  closed  February  2. 
On  February  7  went  home  in  good  health,  able  to  pass  and  retain  urine 
normally.  1  hail  the  pleasure  of  showing  this  case  here  at  a  previous 
lecture.  On  December  27,  1905,  nearly  four  years  after  operation,  he 
writes  :  '  I  am  in  the  best  of  health  and  have  no  urinary  troubles  what- 
ever.    At  night  I  retain  the  water  five  or  six  hours  without  inconvenience. 


4S     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

In  the  daytime,  of  course,  the  intervals  are  shorter  ;  but  then  it  depends 
on  how  much  I  drink.'     The  prostate  (Fig.  14)  weighed  2|  ounces. 

Case  12. — A.  T ,  aged  seventy-six,  sent   by  Dr.  J.   S.  Anderson, 

Hornsey,  April  1,  1902.  Prostatic  symptoms  of  fifteen  years'  duration  ; 
completely  dependent  on  catheter,  thirteen  years ;  much  difficulty  latterly 
in  passing  instrument  ;  profuse  haemorrhage  at  times  ;  condition  very 
distressful  ;  prostate  much  enlarged  per  rectum,  bilobed,  smooth,  elastic, 
movable,  felt  bimanually.     General  health  fair. 

On  April  10,  1902,  I  enucleated  the  prostate  entire  in  its  capsule  at 
St.  Peter's  Hospital.     There  was  an  outgrowth  of  the  left  lobe  in  the 


Fig.  14.— Prostate,  weighing  2}  Ounces,  removed  from  Patient 
aged  Fifty-eight  (Case  9).    Actual  Size. 

Catheter  lies  in  position  occupied  by  urethra. 

bladder  the  size  of  a  walnut.  Dr.  A.  15.  Mitchell,  of  Belfast,  who  was 
present,  informed  me  that  he  had  timed  the  operation  ;  fifteen  minutes 
elapsed  between  commencement  of  the  operation  and  delivery  of  the 
prostate  from  the  bladder. 

The  recovery  was  uneventful.  Some  urine  passed  naturally,  April  23  ; 
wound  closed,  May  16;  discharge  cured,  May  20.  I  saw  him,  June  3, 
in  excellent  health,  with  no  urinary  symptom.  Retained  urine  all  night, 
from  10.30  p.m.  till  8  a.m..  and  passed  it  'better  than  he  ever  did 
previously.'  On  June  4  Dr.  Anderson  wrote  :  'The  results  of  the  opera- 
tion have   been    most    satisfactory.     I    should   never  have  conceived  it 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE    49 

possible  for  anyone  to  obtain  such  complete  relief  as  Mr.  T has  clone 

from  an  affection  that  had  lasted  so  long,  and  was  daily  becoming  more 
and  more  dangerous  to  life.'  This  patient  was  present  at  a  previous 
lecture,  and  related  his  terrible  sufferings  and  complete  cure.  On 
December  28,  1905,  three  and  three-quarter  years  after  operation,  he 
writes  :  '  My  waterworks  are  in  perfect  condition.  Complete  control,  order 
and  peace  exist  in  every  department.     My  appetite  is  good,  and  I  enjoy 


Fig.    15.    Prostate,  weighing   y\   Ounces,  from  Patieni     wjed 
Seventy-six  (Case  ui.    Exact  Si/k. 

b,  1  .  Lateral  lobes  ;    \,  '  middle  lobe'  growing  from  C. 


my  bed  with  it^  sweet  sleep  and  cheerful  dreams.'  The  prostate  (Fig.  15) 
weighed  3 1  ounces. 

<   \-i    [3,     J.  II ,  aged  sixty-eight,  admitted  to  St.  Peter's  Hospital 

.  1902.  Has  suffered  for  twelve  years  from  the  usual  prostatic 
symptoms,  which  Latterly  have  grown  much  worse.  Retention  of  urine  two 
years  and  a  half  ago  ;  since  then  has  used  catheter  regularly,  through 
which  he  pa  1  practically  the  whole  of  his  urine  now.  His  doctoi 
writes,  that  he  has  had  several  attacks  of  cystitis  and  probably  pyelitis, 
with  extreme  feebleness,  weak,  irregular  pulse, and  extreme  pain/render- 

4 


50     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

ing  life  almost  unendurable.'  Urine  alkaline,  specific  gravity  1012, 
albumin,  and  much  muco-pus.  Large  inguinal  hernia  complicates  the 
case.  Prostate  per  rectum  much  enlarged,  rounded,  slightly  bilobed, 
smooth,  tense,  elastic,  and  movable.  By  the  cystoscope  both  lobes 
were  seen  prominent  in  the  bladder. 

On  May  14  I  performed  suprapubic  cystotomy  and  felt  the  lobes  as 
seen  by  the  cystoscope.  By  my  finger-nail  I  scraped  through  the  mucous 
membrane  covering  the  right  lobe  till  the  capsule  was  reached,  and  then 
gradually  separated  it  from  the  sheath  and  urethra.     The  left  lobe  was 


Fig.  16.— Prostate,  weighing  2^  Ounces,  from  Patient  aged 
Sixty-eight  (Case  13).    Actual  Size. 

similarly  dealt  with.  The  lobes  came  away  separately,  leaving  the  urethra 
and  ejaculatory  ducts  intact.     There  was  very  little  bleeding  or  shock. 

Some  urine  passed  naturally  May  30  ;  patient  sitting  up  June  5,  and 
passing  nearly  all  his  urine  by  the  urethra. 

By  June  15  his  wound  was  quite  healed,  and  he  could  pass  and  retain 
urine  as  well  as  he  ever  did.  On  January  3,  1906,  his  doctor  writes  : 
'When  I  last  saw  him  he  was  altered  from  a  decrepit  old  man,  unable  to 
follow  his  work,  to  as  active  and  capable  a  man  of  his  years  as  one  could 
wish  to  find.' 

Fig.  16  shows  the  entire  prostate,  covered  by  its  proper  capsule. 
Lobes  placed  in  proximity  along  their  inferior  commissure. 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE     51 

Case  15. — Distinguished  public  man,  formerly  governor  of  a  province 
in  India,  aged  seventy-nine,  seen  in  consultation  with  Dr.  Scott,  Camberley. 
June  10,  1902.  Prostatic  symptoms  had  existed  three  years  ;  completely 
dependent  on  catheter  for  nine  months  ;  catheterism  painful  and  accom- 
panied by  haemorrhage  at  times,  also  orchitis.  Prostate  much  enlarged 
per  rectum, — particularly  on  the  left, — bilobed,  rather  dense,  but  movable. 

On  June,  23,  Dr.  Scott  assisting,  I  examined  the  patient  cystoscopically, 


Fig.  17.— Prostate,  weighing  2  Ounces,  removed  from  Patieni 
aged  Seventy-nine  (Case  15).    Actual  Size 

1  ,  R  ght  lobe  :  B,  left  lobe,  continued  into  the  bladder  in  the  form  of  a  so- 
called  'middle'  lobe,  \.  The  catheter  shows  the  position  occupied 
by  the  urethra. 

and  saw  a  valvular  outgrowth  from  the  left  lobe,  the  size  of  a  gooseberry. 
I  forthwith  enucleated  the  prostate,  the  lobes  cominj  itely, 

and  the  urethra  being  left  behind.  Ten  minutes  elapsed  from  com- 
mencing the  suprapubic  incision  nil  the  prostate  was  delivered  from 
the  bladder. 

Ill'-  patient  bore  the  operation  well,  but  was  »o  si(  I.  from  the  anaesthetic 
hat  for  thri  e  days  he  had  t"  he  fed  entirely  by  the  rectum.     <  >n  Jun< 

4—2 


52     OPERATION  OF  TOTAL  ENUCLEA  TION  OF  PROSTATE 

the  temperature  rose  to  103'  F.,  and  the  right  parotid  gland  suddenly 
swelled  to  a  large  size,  and  on  July  2  there  was  swelling  of  the  right 
testicle.  Both  glands  subsided  without  suppuration.  What  the  cause  of 
the  swelling  of  the  parotid  was — whether  due  to  chill,  the  result  of  rectal 
feeding,  or  occurring,  as  it  occasionally  does,  after  operations  on  the  pelvic 
viscera  and  abdomen— I  am  unable  to  say.  I  feared  at  first  that  it  might 
be  due  to  septicaemia,  but  this  was  obviously  not  the  case.  Urine  began 
to  pass  naturally  on  July  16,  and  the  abdominal  wound  was  completely 
closed  on  the  27th.  I  saw  this  patient  more  than  three  years  after  the 
operation.  He  was  in  excellent  health,  had  put  on  much  flesh,  and  assured 
me  that  he  passed  and  retained  his  urine  better  than  at  any  period  of  his 
life  previously  to  operation. 

The  prostate  (Fig.  17)  weighed  2  ounces,  with  each  lobe  enveloped  in 
its  true  capsule.  It  is  adenomatous,  but  rather  hard.  It  will  be  observed 
that  the  so-called  'middle  lobe'  (a)  is  merely  an  outgrowth  from  the  left 
lobe  (P.). 

Case  21. — This  gentleman,  aged  sixty-five,  on  the  advice  of  Dr.  Goldie 
of  Auckland,  came  to  me  from  New  Zealand  for  the  purpose  of  having 
his  prostate  removed.  Prostatic  symptoms  for  three  years ;  complete 
retention  of  urine  eighteen  months  ago  relieved  by  catheter,  which  has 
been  employed  ever  since,  practically  all  the  urine  passing  in  this  way. 
Has  used  narcotics  to  relieve  the  pain.  Prostate  enormously  enlarged 
by  rectum,  round,  smooth,  soft,  elastic,  movable  above  rectum.  Cysto- 
scopy on  July  j  6,  1902,  failed  owing  to  bleeding. 

On  July  23,  Mr.  W.  Braine  being  anaesthetist,  I  opened  the  bladder 
suprapubically,  and  enucleated  the  prostate  entire  in  its  capsule,  the  lobes 
separating  along  their  anterior  commissure,  and  the  urethra  being  left 
behind.  The  whole  operation  lasted  twenty-two  minutes,  the  enucleation 
of  the  prostate,  and  its  removal  from  the  bladder  occupying  only  six 
minutes.  There  was  not  much  bleeding,  but  an  hour  and  a  half  after 
operation  there  was  great  shock  and  collapse,  from  which  the  patient 
soon  rallied.  Recovery  uninterrupted  and  rapid.  Urine  began  to  pass 
by  the  urethra  July  31,  and  the  whole  of  it  in  this  way  after  August  6, 
when  the  suprapubic  wound  was  completely  closed.  On  February  8,  1906, 
he  wrote  from  Auckland  :  '  I  am  in  the  best  of  health,  and  have  had  no 
urinary  trouble  or  pain  since  the  operation,  three  and  a  half  years  ago. 
In  fact,  I  feel  as  well  as  I  ever  did  in  my  life  ;  can  hold  or  pass  water  at 
will  like  a  man  of  twenty-one,  although  I  am  in  my  sixty-ninth  year.' 

The  prostate  (Fig.  18)  weighs  4^  ounces,  is  non-symmetric- 
ally  enlarged,  the  left  lobe  being  much  larger  than  the  right, 
with  a  '  middle  '  lobe  behind  the  urethral  orifice,  formed  by 
an  outgrowth  from  the  left  lobe. 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE     53 

Case  23. —  Captain  J ,  aged  seventy-two,    came    from    Wales  to 

consult  me  October  24,  1902,  on  the  advice  of  Dr.  A.  Rees,  of  Cardiff, 
and  Dr.  Ironside,  of  Hampstead.  Prostatic  symptoms  for  nine  years  ; 
retention  of  urine  six  years  ago;  much  pain  and  hematuria  for  four 
years  ;  catheter  regularly  employed  for  three  years. 

I  drew  off  6  ounces  of  turbid  urine  containing  some  pus  and  mucus. 
Sounded,  but  no  stone  found.     Prostate  enormously  enlarged  per  rectum^ 


Fig.  18. — Prostate,  weighing^  Ounces,  removed  from  Path  m 

AGED  Six  in  -i  iyk.     Ac  I  U  \i.  Si/ii. 

\.  •  Middle  '  lobe, growing  from  left  lobe,  b,  which  is  much  more  enlarged 
than  right  lobe,  c. 

bilobed,  smooth,  soft,  clastic,  movable;  suffering  from  chronic  bronchia] 
catarrh.  Pulse  irregular  and  bounding  ;  hiyh  tension.  Patient  very 
stout. 

<  >n  0(  tober  17.  Mr.  C.  Braine  giving  1  bloroform,  Colonel  Lucas,  C.B., 
and  Major  Freyer,  C.M.G.,  being  present,  1  opened  the  bladder  supra- 
pubically.  Prostate  found  much  enlarged  into  bladder,  particularly  the 
left  lobe,  which  projected  like  the  handle  of  a  pistol,  forming  a  so-called 
'middle'  lobe.     The  prostate  was  enucleated  easily  and  rapidly,  the 


54     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

lobes  separating  along  both  commissures  and  coming  away  separately, 
leaving  the  urethra  behind  uninjured.  There  was  very  little  bleeding, 
and  the  operation  was  completed  in  twenty-four  minutes. 

The  recovery  was  uneventful.  Some  urine  passed  naturally  on 
October  20,  and  the  whole  of  it  in  this  way  on  and  after  November  8. 
On  November  27  he  went  home  to  Wales  in  excellent  health,  untroubled 
by  any  urinary  symptoms.     On  December  1    he  wrote  :  '  I  am   feeling 


Fig.  19. — Prostate,  weighing  6i  Ounces,  removed  from  Patient 
aged  Seventy-two  (Case  23).    Actual  Size. 

C,  Pistol-shaped  continuation  of  left  lobe,  A,  forming  so-called  'middle 
lobe,'  which  obstructed  entrance  of  catheter  ;  B,  right  lobe. 


splendid.  I  now  make  water  freely,  and  have  thorough  control  of  it.' 
On  November  27,  1904,  he  wrote  :  '  This  being  the  anniversary  of  my 
leaving  your  care  two  years  ago,  I  cannot  let  it  pass  without  thanking  you 
for  the  splendid  work  you  did  on  me.' 

Fig.   19  is  the  prostate,  weighing  6\  ounces.     The  left  lobe  (a)  was 
continued  into  the  bladder,  forming  a  projection  like  the  handle  of  a 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE     55 

pistol — the  so-called  '  middle '  lobe — and  obstructed  the  entrance  of  the 
catheter. 

Cask  24. — J.  H ,  aged  sixty-six,  sent  by  Dr.  William  Curtis,  Alton, 

Hants,  August  5,  1902.  Prostatic  symptoms  for  thirty  years.  Retention 
twenty-four  years  ago  ;  urine  drawn  off  by  Dr.  Curtis.  Since  then  no 
urine  passed  except  by  catheter.  During  last  two  years  in  great  agony 
from  usual  symptoms  of  stone,  superadded  to  those  of  enlarged  prostate. 
Has  had  numerous  attacks  of  cystitis  with  fever.  Catheter  now  required 
every  half  to  one  hour.  Inguinal  hernia  requiring  a  truss.  Patient 
extremely  feeble,  anaemic,  and  much  depressed.  I  drew  off  3  ounces  of 
stinking  urine  containing  blood,  pus,  and  mucus.  Sounded,  and  multiple 
calculi  detected.  Prostate  enormously  enlarged  per  rectum  bilaterally, 
soft,  elastic,  movable,  placed  high  up,  so  that  the  finger  cannot  reach 
beyond  it. 

Litholapaxy  in  September,  debris  of  calculi  weighing  180  grains. 
Thirteen  days  under  treatment,  when  he  left  for  home  to  recruit  his  health 
preliminary  to  undergoing  operation  for  removal  of  prostate. 

Returned  on  November  _|.  Bladder  washed  out  twice  daily  to  improve 
its  condition.  On  November  12,  1902,  I  removed  the  prostate,  both 
lobes  of  which  were  unusually  prominent  in  the  bladder.  The  lobes 
separated  along  both  commissure^  and  came  away  separately,  leaving 
the  urethra  behind.  There  was  considerable  haemorrhage  and  shock, 
and  for  several  days  patient  suffered  much  from  nausea.  The  wound 
was  slow  in  healing,  no  urine  passing  naturally  till  December  15.  On 
December  28  the  suprapubic  wound  had  closed,  and  on  January  6  he 
went  home  quite  well,  passing  and  retaining  his  urine  naturally.  On 
January  <S  Dr.  Curtis  wrote:  "I  am  perfectly  delighted  with  the  result. 
It  is  a  triumph  of  surgery.'  On  December  27,  190:,  more  than  three 
years  after  operation,  the  patient  writes  :  '  1  am  thankful  to  be  able  to  say 
I  have  none  of  my  old  troubles  since  the  operation.  I  am  in  fairly  good 
health,  and  free  from  all  tin-  old  agonizing  pain.' 

Fig.  20  is   the  prostate,  weighing  <  ;  ounces,  the  lobes  (a,  b)  being 
d  m  apposition  as  before  removal.     On  the  prominent  portions  in 
the   bladder     at    <  .  <  ')  are   ulcers,  no   doubt    caused   by    the   calculi   pre- 
viously removed  by  litholapaxy. 

1  25.  <  aptain  E ,  aged  sixty-eight  years,  came  from  Argyll- 
shire t6  consult  me  November  17.  1902,  on  the  advice  of  Mr.  G.  Hender- 
son, of  Kirn.  There  had  been  prostatic  symptoms  for  nine  years,  and  the 
urine  had  been  drawn  off  by  catheter  entirely  for  si\  years.  During  the 
last  three  years  then-  had  been  frequent  attacks  of  cystitis  and  haemor 
rhage,  blocking  the  catheter,  which  had  to  be  passed  every  hour  day  and 
night.  The  pain  had  been  excruciating,  requiring  morphine  to  subdue 
it,  and  the  urine  was  thick  with  pus  and  muCUS.      '  Is  now  m  Mich  .1   Si 


56     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

wrote  Mr.  Henderson,  '  that  he  would  submit  to  anything  rather  than  go 
on  suffering  as  at  present.'  I  drew  off  a  couple  of  ounces  of  urine  thick 
with  pus,  mucus,  and  blood,  and  of  a  fearful  stench,  and  with  the  soft 
catheter  detected  calculi  in  the  bladder.  Upon  sounding  it  was  found 
that  many  calculi  were  present.     The  prostate  was  enormously  enlarged 


\\ 


Fig.  20. — Prostate,  weighing  6|  Ounces,  removed  from  Patient 
aged  Sixty-six  (Case  24). 

A,  ]i,  Lateral  lobes  ;  C,  c',  ulcers  on  prominent  portions  in  bladder  caused 

by  calculi. 

per  rectum,  bilobed,  rather  hard,  nodulated,  but  movable.     The  patient 
was  emaciated,  but  wiry. 
On  November  29,  assisted  by  Mr.  D.  S.  Wylie,  Major  S-  F.  Freyer 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE     57 

and  Major  C.  W.  Johnson  being  present.  I  opened  the  bladder  supra- 
pubically  and  found  it  full  of  calculi,  varying  in  size  from  a  hazel-nut 
downwards,  each  faceted  and  all  composed   of  phosphates.      These  I 


Fig.  31.     [ar  containing  Ninety-six  Entire  Calculi  ind  DSbris 

01  OTHERS,  WEIGHING  5  ,;  <  )i  ,\<  ES,  REMOVED  FROM    l  ill    111  VDDER 
of  Cask  .25. 

extracted  by  forceps  and  scoop,  the  process  being  .1  lengthy  one, 
occupying  thirty-five  minutes.  There  unc  ninety-six  calculi  counted, 
besides  the  debris  of  many  more,  weij  ounces  (Fig.  21).     l  li<- 


58     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

prostate  was  then  enucleated  as  a  whole  in  its  capsule,  the  lateral  lobes 
separating  along  their  anterior  commissure,  and  the  urethra  being  left 
behind.  The  prostate  was  so  large  that  it  had  to  be  divided  into  its  two 
lobes  by  the  finger  to  facilitate  its  removal.  The  enucleation  and  removal 
occupied  five  minutes.  Though  there  was  free  bleeding  during  the 
removal  of  the  calculi,  there  was  practically  none  during  the  removal  of 
the  prostate.     Convalescence  was  established  without  any  rise  of  tem- 


Fig.  22. — Prostate,  weighing  6|  Ounces,  removed  from  Patient 
aged  Sixty-eight  (Case  25).    Actual  Size. 

b,  Right  lobe  ;  A,  left  lobe.  The  vesical  end  of  B  shows  an  ulcer  caused 
by  the  calculi.  The  catheter  shows  the  tortuous  course  of  the 
urethra. 


perature  or  other  unfavourable  symptom.  Some  urine  passed  naturally 
on  December  6,  and  the  whole  of  it  thus  on  and  after  December  12.  On 
December  30  the  patient  travelled  home  to  Argyllshire  in  perfect  health, 
having  put  on  much  flesh,  and  being  able  to  pass  and  retain  his  urine 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE     59 

naturally.  On  July  2,  1904,  he  wrote  :  '  I  am  glad  to  say  that  I  am  Ai — 
50  pounds  heavier  than  when  you  first  saw  me,  November  15,  1902.  My 
everlasting  gratitude  to  you.'  And  on  February  22,  1906  :  '  The  urinary 
organs  are  in  excellent  condition.  I  sleep  six  and  seven  hours  on  a 
stretch  without  inconvenience.  Since  the  day  you  relieved  me  I  have 
never  had  an  ache  or  pain  of  any  sort  whatever.' 

The  prostate  (Fig.  22)  weighs  6^  ounces.     The  catheter  shows  the 


Fig.  23. — Prostate,  weighing  5'  Oun<  es,  ri  moved  i  rom  Patieni 

AGED   Sh\  1  \  1  \  -( >NE  (C  VSE   37). 

The  constriction  ai    \,   \'  is  the  boundary  between  the  intravesical  and 
cxtravesical  portions  of  the  gland. 

tortuous  shape  of  the  urethra.     The  end  of  the  right  lobe  (1:1  projecting 
into  the  bladder  is  ulcerated,  the  result  of  the  calculi. 

Case  37. — Gentleman,  aged  seventy-one,  consulted  me  March  16, 
1903,  on  the  advice  of  Dr.  J.  F.  Tuohy,  of  Hove.  Five  year-  previously 
had  hsematuria  for  two  days  aftei  a  game  of  tennis.  Consulted  two 
1  ondon  surgeons,  one  of  «  bom  sounded  him  and  washed  out  hi^  bladder 
in  a  home  for  several   day-.     Scalding    and   increased   frequencj    of 


60     OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

micturition  ever  since.  Three  weeks  previously  haemorrhage  set  in  again, 
when  he  saw  Dr.  Tuohy,  who  found  he  had  a  large  quantity  of  residual 
urine,  the  result  of  a  very  much  enlarged  prostate,  and  advised  him  to 
have  the  prostate  removed.  Catheter  employed  twice  daily.  I  drew  off 
8  ounces  of  residual  urine,  which  was  turbid  from  muco-pus.  Prostate 
greatly  enlarged  per  rectum,  markedly  bilobed,  soft,  tense,  smooth, 
movable  :  felt  bimanually  like  a  large  orange. 


•S>^t//t)> 


Fig.  24.— Prostate,  weighing  3t  Ounces,  removed  from  Patient 

aged  Seventy-three  (Case  136). 

a,  Right  lobe  ;  A,  left  lobe,  terminating  in  fan-shaped  outgrowth,  C,  c'. 


On  March  18,  Dr.  Tuohy  assisting,  I  removed  the  prostate  entire  in  its 
capsule,  the  urethra  being  left  behind.  Both  lobes  were  very  prominent 
in  the  bladder — almost  pedunculated  outgrowths.  The  enucleation  was 
easy  and  rapid,  only  ten  minutes  elapsing  from  commencing  the  supra- 
pubic incision  till  the  prostate  was  delivered  from  the  bladder.  Scarcely 
any  bleeding  or  shock.  The  patient  made  an  uninterrupted  recovery, 
the  temperature  remaining  practically  normal  throughout.  Urine  began 
to  pass  naturally  April  14,  and  the  wound  was  quite  closed  April  19. 
Went  home  to  Brighton  April  23  in  good  health,  able  to  retain  and  pass 


OPERATION  OF  TOTAL  ENUCLEATION  OF  PROSTATE     61 

his  urine  as  well  as  he  ever  did.  I  have  met  this  gentleman  frequently 
since  then  in  perfect  health.  On  December  29,  J905,  more  than  two 
years  and  nine  months  after  operation,  he  writes  :  '  I  could  not  have  been 
doing  better.     The  operation  was  a  complete  success.' 

The  prostate  (Fig.  23)  is  a  fine  specimen  of  the  symmetrically  enlarged 
type,  weighing  55  ounces. 

Case  136. — Member  of  the  medical  profession,  aged  seventy- three, 
consulted  me  October  4,  1904.  Symptoms  of  enlarged  prostate  seven 
years  ;  entirely  dependent  on  catheter  five  years.  Urine  clear,  acid, 
specific  gravity  1020,  trace  of  albumin.  Prostate  greatly  enlarged,  bilobed, 
soft,  movable,  felt  very  prominent  in  bladder  bimanually.  Mitral  disease 
of  heart,  with  loud  bruit.  Seen  by  Sir  Thomas  Barlow  and  Dr.de  Havil- 
land  Hall,  both  of  whom  considered  that  the  state  of  the  heart  did  not 
contraindicate  the  employment  of  an  anaesthetic,  provided  he  had  a  week's 
rest  in  bed  with  careful  dieting. 

On  October  25,  Dr.  Hewett  being  anaesthetist  and  Mr.  H.  W.  Carson 
being  present,  I  enucleated  the  prostate  (weighing  3J  ounces),  the  lobes 
of  which  were  very  prominent  in  the  bladder,  particularly  the  left 
(Fig.  24  A),  which  spread  out  in  the  form  of  a  fan  (C,  C').  In  the 
enucleation  a  small  portion  of  the  left  lobe  was  broken  off  owing  to 
inflammatory  adhesions  to  the  bladder,  and  was  removed  separately. 
Time,  six  minutes  ;  scarcely  any  bleeding  and  no  shock — in  fact,  the 
pulse  was  better  after  the  operation  than  before. 

Recovered  without  any  unfavourable  symptom.  Urine  passed  naturally 
November  9  ;  wound  dry  November  14.  Left  the  surgical  home  quite 
well  November  26  ;  able  to  retain  and  pass  urine  as  well  as  ever.  He  is 
now  in  active  pursuit  of  his  profession.  On  October  29,  1905,  a  year  after 
operation,  he  write-. :  So  far  as  urinary  troubles  are  concerned,  I  have 
kept  perfectly  right  since  leaving  the  home.  Micturition  is  more  free 
than  it  has  been  probably  since  childhood.' 


LECTURE  IV 

I.— DEVELOPMENTS  OF  THE  AUTHORS  OPERATION 
INVOLVING  PARTIAL  OR  TOTAL  REMOVAL  OF  THE 
PROSTATIC  URETHRA 

When  I  first  conceived  the  possibility  of  removing  the  whole 
prostate,  my  ideal  operation  consisted,  as  already  stated,  in 
enucleating  the  enlarged  gland  entire  in  its  capsule  out  of 
the  enveloping  sheath,  leaving  the  urethra  behind ;  and  this 
was  the  procedure  undertaken  in  my  earlier  cases.  An 
accident  which  occurred  during  the  operation  on  my  eighth 
case  had,  however,  the  effect  of  materially  modifying  my 
views  in  this  respect.  In  a  lecture  delivered  on  January  15, 
1902,  on  my  second  series  of  four  cases  of  the  operation, 
and  published  in  the  British  Medical  Journal  of  February  1 
of  the  same  year,  I  introduced  the  description  of  this  case  in 
the  following  words  :  '  I  now  pass  on  to  the  eighth  case,  which 
presents  some  peculiarities,  not  the  least  interesting  being 
that,  though  in  the  removal  of  the  prostate  as  a  whole  the 
urethra  was  undesignedly  torn  across  at  its  junction  with  the 
bladder,  no  untoward  result  ensued,  the  patient  making  a 
thorough  recovery.'     The  details  of  the  case  are  these  : 

Case  8. — This  patient,  aged  sixty-five  years,  had  a  history  of  prostatic 
symptoms  for  ten  years,  much  aggravated  during  the  last  two  and  a  half 
years,  particularly  as  the  introduction  of  the  catheter  caused  haemorrhage. 
The  prostate  was  felt  to  be  greatly  enlarged  per  rectum,  tense,  elastic, 
smooth,  globular,  and  quite  movable.  Cystoscopic  examination  revealed 
an  irregular  bulging  into  the  bladder  all  round  its  neck. 

62 


RE  MO  I  'A  L   OF  THE  ) "ROSEA  Til '  i  'RE  EIIRA 


63 


On  December  11,  1901,  I  operated.  After  enucleating  the  prostate 
in  its  capsule  from  the  sheath  all  round,  I  felt  the  catheter  passing  through 
its  axis  the  urethra),  and  that  the  lobes  had  not  separated  either  along 
the  anterior  or  posterior  commissure.  Passing  my  finger  along  the 
anterior  commissure,  counter-pressure  being  made  by  the  finger  in  the 
rectum,  I  endeavoured  to  separate  the  lobes,  when  suddenly  the  whole 
mass  was  propelled  into  the  bladder.     The  urethra  was  then  felt  covering 


1 


/, 


Fig.  25.     Pear-shaped   Prostate,  weighini  ived 

from  patien  i   aged  si  x  i  vi  i  . 


the  catheter,  but  severed  ;it  its  vesical  end.  <  )n  examination  of  the 
prostate  after  removal  I  found  that  it  was  pear-shaped,  and  that  it  had 
been  drawn  from  the  urethra,  which  was  severed  at  the  neck  of  the 
bladder,  just  as  a  bead  is  drawn  from  a  string.  There  were  more  haemor- 
rhage And  shock  than  in  the  previous  but  the  patient  math-  a 
thorough  recovery.  Nine  months  after  the  operation  I  had  the  pleasure 
of  showing  this  patient  at  the  East  Anglian  branch  of  the  British  Medical 
in.      He  was   in   perfect   health,  aide   tO   pass  and   to    retain   hi^ 


64  REMOVAL   OF  THE  PROSTATIC  URETHRA 

urine  as  well  as  he  ever  did.  On  December  30,  1905,  four  years  after 
operation,  he  writes  :  '  I  can  both  pass  and  retain  urine  quite  comfortably 
and  satisfactorily,  thanks  to  your  wonderful  operation.  Indeed,  I  have  no 
pains  now,  and  life  has  become  worth  living  ;  but,  as  you  know,  without 
your  operation  I  could  not  have  lived  a  fortnight.' 

In  a  further  lecture  published  in  the  British  Medical 
Journal  of  July  26,  1902,  I  commented  on  this  and  cases  of 
a  somewhat  similar  nature  in  the  following  terms : 

'  In  my  previous  lecture,  in  giving  details  of  my  eighth 
case  of  this  operation,  I  described  how,  whilst  endeavouring 
to  separate  the  prostatic  lobes  along  their  anterior  com- 
missure so  as  to  leave  the  urethra  behind  intact,  the  urethra 
was  undesignedly  torn  across,  and  -the  prostate  propelled  as 
a  whole  into  the  bladder  by  the  force  of  the  finger  in  the 
rectum.  This  patient  made  an  excellent  recovery,  and  is 
now  in  good  health,  untroubled  by  any  urinary  symptom. 
The  success  that  attended  this  case  emboldened  me  to 
deliberately  tear  the  urethra  across  in  Cases  10,  11,  and  14, 
and  to  remove  a  portion  or  the  whole  of  the  prostatic  urethra, 
when  it  was  found  that  the  enlargement  had  not  sufficiently 
advanced  to  define  and  loosen  the  lobes  along  either  the 
anterior  or  posterior  commissure,  so  as  to  enable  one  to  peel 
the  prostate  off  the  urethra  and  leave  the  latter  behind 
intact,  with  the  successful  results  already  described.  The 
success  that  has  attended  these  latter  cases  is  of  weighty 
import,  indicating,  as  it  does,  that  we  may  remove  the 
prostate  at  an  earlier  stage  in  its  growth,  and  that  when  it  is 
found  impossible  to  separate  it  from  the  urethra,  we  may, 
without  hesitation,  boldly  tear  across  or  even  remove  the 
latter  with  impunity.' 

The  details  of  Case  10  are  as  follows  : 

Case  10. — C.  C ,  aged  fifty-nine,  suffered  from  the  usual  prostatic 

symptoms  for  twelve  years  ;  of  great  severity  latterly,  haemorrhage 
accompanying  the  use  of  the  catheter.  Prostate  much  enlarged  per 
rccium,  rounded,  scarcely  bilobed,  placed  high  in  rectum.     Cystoscopy 


REMOVAL  OF  THE  PROSTATIC  URETHRA  65 

at  St.  Peter's  Hospital  on  June  6,  1901,  showed  both  lobes  prominent  in 
the  bladder,  and  two  small,  oval,  smooth,  fawn-coloured  calculi  lying 
behind  the  prostate.  Litholapaxy  was  at  once  performed,  the  uric  acid 
debris  weighing  42  grains.     Recovery  uneventful. 

The  prostatic  symptoms  continuing  to  increase  in  severity,  on  the 
advice  of  Dr.  Collins,  Peterborough,  the  patient  returned  in  January. 
1902  ;  and  on  February  5  I  removed  the  prostate  (Fig.  26),  weighing 
2{  ounces,  as  a  whole,  with  the  urethra  attached.  The  patient  was  very 
ill  for  some  days,  with  distended  abdomen,  pain  and  tenderness  in  the 
left  loin  and  groin,  causing  much  anxiety.     These  symptoms    however 


Fig.  26.— Prostate,  weighing  2  .  ri  moved  1  rom  Patieni 

ag]  i'  i'ii  n-\i\i   (Case  10). 

\,  1;.  I.  iteral  lubes  ;  C,  C',  muscular  and  fibrous  band  from  sheath  outside 

prostate. 

Subsided,  and  on  February  17  some  urine  passed  per  itnt/traiu,  but  the 
suprapubic  wound  was  not  entirely  closed  till  March  15.  On  March  24 
he  left  for  home  quite  well,  passing  and  retaining  his  urine  normally.  On 
January  7,  1906,  nearly  four  years  after  operation,  he  wrote:  'I  am 
keeping  in  good  health  and  have  not  lost  a  day's  work  for  over  nineteen 
months.  I  have  \\.\A  no  urinary  troubles  since  I  saw  you.1  « m 
uary  1  ;.  1906,  he  came  to  see  me  at  the  hospital  in  perfect  health, 
able  to  pass  and  retain  his  urine,  which  was  normal,  as  well  as  he  ever 
did. 


66  REMOVAL  OF  THE  PROSTATIC  URETHRA 

In  my  fourth,  fifth,  and  sixth  series  of  cases  of  the  opera- 
tion, published  respectively  in  the  issues  of  the  British 
Medical  Journal  of  November  8,  1902,  April  18  and  July  4, 
1903,  several  instances  are  recorded  of  removal  of  the 
prostatic  urethra  with  the  entire  gland.  I  will  give  an 
example  from  each  series  : 

Case   16. — General  B ,  aged  sixty-seven,  sent  by  Mr.  Jowers,  of 

Brighton,  June    20,   1902.      Prostatic   symptoms    for  five  years  ;  latterly 


Fig.  27. — Prostate,  weighing  2^  Ounces,  removed  from  Patient 
aged  Sixty-seven  (Case  16).    Actual  Size. 

a.  Tongue-shaped  'middle'  lobe  growing  from  lateral  lobes,  B,  c,  but 
mainly  from  left  ;  B,  D,  band  of  sheath  encircling  lateral  lobes. 

combined  with  those  of  stone  in  the  bladder.  Great  frequency  of 
micturition  by  day  and  night,  with  intense  pain  ;  passing  blood  in  urine 
for'years.  The  passage  of  the  catheter,  which  is  employed  three  or  four 
times  daily,  causes  intense  pain.  Patient  in  a  very  miserable  condition, 
utterly  unnerved  from  the  pain  and  want  of  sleep  ;  constantly  using 
narcotics ;  wears  a  urinal  in  bed. 


REMOVAL   OF  THE  PROSTATIC  URETHRA  67 

Prostate  much  enlarged  per  rectum,  bilobed,  smooth,  soft,  tense 
movable  ;  urine  alkaline,  contains  much  pus  and  blood.  Sounded,  but 
no  stone  detected.  Cystoscopy  on  June  23 — Dr.  Dudley  Buxton,  anaesthe- 
tist :  Dr.  J.  Anderson,  CLE.,  and  Colonel  Coates,  [.M.S.,  present — 
revealed  a  large  tongue-shaped  outgrowth  of  the  prostate  in  the  bladder, 
and  below  this  calculi  lying  like  eggs  in  a  nest. 

I  forthwith  opened  the  bladder  suprapubically  and  removed  four 
smooth  urate  calculi,  weighing  over  2  drachms,  from  a  pouch  behind  the 
prostate.  I  then  enucleated  the  prostate  (Fig.  27).  weighing  z\  ounces, 
as  a  whole.  The  latter  failed  to  separate  along  its  anterior  commissure, 
so  I  tore  the  urethra  across  at  the  neck  of  the  bladder,  and  peeled  the 
prostate  off  the  urethra.  There  was  very  little  bleeding  and  no  shock. 
During  the  first  week  the  patient  made  excellent  progress,  being  able 
from  the  first  to  move  about  in  bed.  Then  some  mental  disturbance  set 
in,  which,  however,  passed  off  in  a  few  days.  Urine  passed  naturally 
July  10,  and  wound  was  completely  closed  July  25.  1  have  met  this 
patient  frequently  since  then.  He  is  now  in  excellent  health,  untroubled 
by  any  urinary  symptoms. 

Case  28. — On  November  16,  1902,  I  was  summoned  to  Stockport  to 
see  a  patient  in  consultation  with  Dr.  Hyde  Marriott,  of  that  place,  and 
Mr.  1".  A.  Southam,  of  Manchester.  Prostatic  symptoms  had  been 
present  for  seven  years,  the  catheter  having  been  used  from  two  to  four 
times  daily  for  five  years  ;  latterly,  this  was  attended  by  much  difficulty  of 
introduction  and  luemorrhage.  The  patient  had  suffered  from  retention 
of  urine  in  Brussels  in  the  previous  summer,  when  26  ounces  were  drawn 
off  by  a  Belgian  surgeon.  Subsequently  profuse  haemorrhage  had 
occurred,  necessitating  the  tying  in  of  a  catheter  for  four  days,  when  the 
patient's  life  was  despaired  of.  Latterly  the  bleeding  had  in*  reaped  in 
frequency,  and  when  I  saw  him  in  consultation  he  was  confined  to  bed 
from  weakness  caused  thereby.  1  passed  a  eoudee  No.  8,  and  drew  oil 
eight  ounces  of  blood-stained  urine  containing  pus  and  mucus.  The 
prostate  was  fit  t>>  be  greatly  enlarged  per  rectum,  bilobed,  smooth. 
tense,  soft,  and  movable.  In  consultation  it  was  decided  that  tin 
was  I'D'-  suitable  for  removal  of  the  prostate,  the  only  drawback  being 
that  the  patient  was  very  stout. 

( )n  December  4  he  was  sufficiently  strong  to  travel  to  London,  and  on 
December  <s  1  removed  the  prostate,  Major  Freyer  ami  Dr.  Marriott 
assisting.  The  prostate  came  away  entire,  together  with  a  thin  layer  of 
the  re  to  vesical  fast  ia,  or  sheath,  which  was  adherenl  from  old-standing 
inflammation.  The  prostatic  urethra  was  also  removed.  Nine  minutes 
elapsed  from  the  time  of  taking  the  knife  in  hand  to  open  the  bladder 
suprapubically  to  that  of  the  prostate  being  delivered  from  tin-  Madder. 
Some  mine  passed  per  uretkram  on  Decembei  20,  and  was  wholly  passed 
by  this  channel  on  December  24,  after  which  the  suprapubi<  wound  did 

5—-' 


68 


REMOVAL  OF  THE  PROSTATIC  URETHRA 


not  reopen,  and  convalescence  was  established  without  rise  of  tempera- 
ture. The  only  interruption  to  the  progress  of  the  case  was  an  attack 
of  biliary  colic  with  jaundice,  for  which  the  patient  was  seen  by  Sir 
Thomas  Barlow  with  me  ;  this  gradually  subsided.  After  January  3, 
1903,  the  patient  walked  out  daily,  and  on  the   8th  he  went   home    to 


Fig.  20.— Prostate,  weighing  5^  Ounces,  removed  erom  Patient 

aged  slxtv-three  (case  28).    actual  slze. 

a,  .\'.  1:,  b',  Lateral  lobes  covered  by  the  true  capsule  and  encircled  by 

thin  band,  c,  of  the  sheath,  removed  with  the  prostate. 

Stockport,  able  to  pass  and  to  retain  his  urine  naturally.  I  have  seen 
this  patient  on  several  occasions  since  then.  He  is  in  perfect  health, 
untroubled  by  any  urinary  symptoms,  and  is  actively  engaged  in  his 
business.     On  February  24,  1906,  he  wrote  :  '  I  never  felt  better.     I  have 


REMOVAL  OF  THE  PROSTATIC  URETHRA 


69 


never  felt  ache  or  pain  since  the  operation,  or  any  ill-effects.  I  retain 
my  water  as  well  as  ever  I  did,  and  have  no  trouble.  I  never  passed  it 
better  in  my  life.  I  call  it  a  complete  renewal  of  life,  and  making 
one's  latter  days  a  very  great  pleasure.  I  stick  to  business,  a  good  full 
ten  hours  a  day,  and  enjoy  it.5  The  prostate  (Fig.  28)  weighs  5  j 
ounces. 


Fig.  29.  -  Prostai  e,  weighing  6£  Ounces,  removed  from  Patieni 
vged  Fifty-seven  ((  ise  38).    Ai  n  \i.  £ 

\,  \\  Enormously  enlarged  right  lobe  terminating  in  pistol-shaped  pn 
tion,  a,  in  the  bladder  ;   B,   r.',  left  lobe  ;   c,  thin  band  of  sheath 
removed  with  the  prosi  ite. 

Casi    }8. — The  patient,  who  vv.i^  fifty-seven  years  of  age,  was  adm 
to  St.  Peter's  Hospital  March  10,  1903.     He  had  had  retention  <>f  urine 
six   /ears   previously,  and   the  usual   prostatic    symptoms    Mine   then 


jo  REMOVAL  OF  THE  PROSTATIC  URETHRA 

gradually  increasing.  The  catheter  had  been  in  habitual  use  for  two 
years,  and  the  urine  had  been  entirely  passed  in  this  way  for  twelve 
months.  There  had  been  difficulty  in  passing  the  catheter.  The 
prostate  was  much  enlarged  per  rectum,  bilobed,  soft,  tense,  movable, 
and  felt  greatly  enlarged  bimanually. 

On  March  1 8  I  removed  the  prostate  (Fig.  29)  entire.  The  capsule 
was  adherent  to  the  sheath,  and  in  the  enucleation  a  thin  band  of  the 
latter  (c)  was  removed  with  the  prostate  as  well  as  a  portion  of  the 
prostatic  urethra.  The  patient  made  an  excellent  recovery  ;  he  began  to 
pass  urine  naturally  on  the  30th,  and  the  wound  was  dry  on  April  6.  He 
was  discharged  on  the  iSth.  I  had  the  pleasure  of  showing  the  patient 
at  the  Medical  Graduates'  College  in  May,  1903,  in  perfect  health,  and 
able  to  pass  and  to  retain  his  urine  quite  naturally.  On  July  1,  1904,  he 
writes :  '  I  am  glad  to  say  that  I  have  no  urinary  trouble,  and  that  the 
operation  was  most  successful,  and  my  health  has  been  good.'  And  on 
February  26,  1906  :  '  I  am  very  well.  The  waterworks  are  in  good  going 
condition.     I  have  not  had  any  trouble  with  them  since  the  operation.1 

The  prostate  (Fig.  29),  which  weighs  6*  ounces,  is  a  fine  specimen  of 
the  non-symmetrically  enlarged  organ,  the  right  lobe  (a,  a')  being 
enormously  enlarged  in  the  bladder,  and  forming  a  pistol-shaped  valve 
(a)  to  the  urethral  orifice.  The  great  size  of  the  prostate  is  remarkable 
in  a  man  of  the  age  of  the  patient. 

I  have  described  the  evolution  of  my  views  and  procedure 
in  this  matter  of  the  removal  of  the  urethra  with  the  prostate 
as  a  whole  historically,  because  I  have  observed  that  in 
the  Annals  of  Surgery,  for  January,  1904,  Mr.  Moynihan  of 
Leeds,  without  any  recognition  of  my  previously  published 
writings  on  the  subject,  implies  originality  on  his  part  for 
this  procedure.  In  the  paper  referred  to,  this  gentleman 
has  assumed  the  role  of  critic  of  my  work,  and  was  therefore, 
it  is  to  be  presumed,  acquainted  with  my  published  writings 
on  the  subject — a  fact  which  renders  his  conduct  in  this 
matter  all  the  more  extraordinary.  It  is,  indeed,  a  remark- 
able coincident  that  even  the  phraseology  employed  by  him 
in  describing  his  imaginary  discovery  should  happen  to  be 
practically  the  same  in  some  instances  as  that  employed  by 
me  in  the  above  quotations  from  lectures  published  in  the 
British  Medical  Journal  about  two  and  one  and  a  half  years 
previously. 


REMOVAL   OF  THE  PROSTATIC  URETHRA  71 

I  have  latterly  almost  completely  abandoned  the  attempt 
to  preserve  the  urethra  entire  in  the  enucleation  of  the 
prostate.  The  excellent  permanent  results  obtained  from 
partial  removal  of  the  urethra  with  the  organ  have  convinced 
me  that  no  advantage  is  to  be  gained  by  leaving  the  vesical 
end  of  the  urethra  behind.  In  a  large  proportion  of  cases  of 
enlarged  prostate  this  vesical  end  of  the  urethra  is  extremely 
dilated,  being  trumpet-shaped,  or  distorted  out  of  any  shape 
resembling  a  more  or  less  circular  tube  as  in  the  normal 
prostatic  urethra.  Even  when  it  was  left  behind,  I  have 
always  had  my  doubts  as  to  its  ultimate  fate  in  most 
instances.  The  probability  is  that,  through  want  of  support 
and  adequate  blood-supply,  it  sloughed  in  large  part,  and 
came  away  in  the  washings  during  the  after-treatment. 

Examination  of  specimens  of  prostate  which,  in  removal, 
have  opened  along  the  anterior  commissure — to  which 
category  the  great  majority  belong — will  show  that  the 
dilated  portion  of  the  prostatic  urethra — viz.,  that  portion 
lying  between  the  verumontanum  and  the  vesical  outlet, 
has  come  away  with  the  prostate,  the  urethra  in  front  of  this 
being  left  behind.  The  portion  of  the  urethra  behind  the 
point  at  which  the  ejaculatory  ducts  enter  it  is  much  more 
adherent  to  the  prostate  than  that  in  front  of  it,  between  this 
point  and  the  triangular  ligament.  In  fact,  in  the  greatly 
enlarged  prostate  this  latter  portion  lies  quite  loosely  attached 
to  the  lobes  on  either  side.  When  such  a  prostate  is 
enucleated  in  its  capsule  from  the  sheath  all  round,  and  the 
lobes  are  gently  separated  from  the  triangular  ligament  by 
the  point  of  the  linger,  the  organ  can  be  felt  hanging  on  by 
the  urethra  and  ejaculatory  ducts;  and  the  linger-point  can 
be  easily  inserted  on  either  side  between  the  inferior  portion 
of  the  prostatic  lobe  and  the  urethra.  If  now  the  finger-tip 
be  placed  behind  the  prostate  in  the  median  line  above  the 
ejaculatory  ducts,  and  the   prostate   be  propelled   upwards 


72  THE  AFTER-TREATMENT  OF  PROSTATECTOMY 

into  the  bladder  by  the  finger  in  the  rectum,  the  urethra  will 
be  found  to  snap  across  at  the  verumontanum,  leaving  the 
ejaculatory  ducts,  as  a  rule,  adherent  to  the  portion  of  the 
prostatic  urethra  left  behind. 


II.— THE  AFTER-TREATMENT  OF  PROSTATECTOMY. 

With  the  delivery  of  the  prostate  from  the  bladder  the 
essential  part  of  the  operation  may  be  regarded  as  completed. 

The  forefinger  of  one  hand  is  reintroduced  into  the 
bladder  forthwith,  and  that  of  the  other  hand  into  the 
rectum.  The  opposing  surfaces  of  the  cavity,  from  which 
the  prostate  has  been  enucleated,  are  then  pressed  together 
all  round  the  vesical  orifice  between  the  tips  of  the  fingers. 
By  thoroughly  kneading  the  opposed  surfaces  together  in 
this  manner  the  contraction  of  the  cavity,  and  its  diminution 
in  size,  are  facilitated,  and  haemorrhage  is  thus  arrested,  just 
as  a  dentist  presses  the  gum  together  after  the  extraction  of 
a  tooth,  or  the  accoucheur  does  the  flaccid  womb  after 
parturition,  with  a  similar  object  in  view. 

The  bladder  is  then  irrigated  with  hot  boracic  lotion 
(temperature  about  no0  F.),  through  the  catheter  still  in  situ, 
for  the  purpose  of  removing  clots  and,  further,  to  control 
bleeding.  This  process  should  not,  however,  be  continued 
for  more  than  two  or  three  minutes,  as  I  find  from  experience 
that  these  irrigations  not  unfrequently  promote  bleeding 
instead  of  diminishing  it,  if  the  irrigation  be  continued  too 
long.  This  I  attribute  to  the  prostatic  cavity  being  distended 
by  the  pressure  of  the  fluid  in  the  bladder. 

The  bladder  having  been  cleared  of  clots,  and  whilst  the 
irrigation  is  still  proceeding,  a  stout  indiarubber  drainage- 
tube  is  introduced  through  the  suprapubic  wound.  The 
dimensions  and  management  of  this  tube  I  regard  as  of  the 
utmost  importance  in  the  after-treatment  of  this  operation. 


THE  AFTER-TREATMENT  OF  PROSTATECTOMY         73 

I  have  been  gradually  increasing  the  calibre  of  this  tube,  till 
I  now  invariably  employ  ^-inch  tubing,  with  a  lumen  $  inch 
in  diameter.  Two  large  perforations,  or  eyes,  are  made 
as  near  as  possible  to  the  vesical  end  of  this  tube  (Fig.  30), 
on  opposite  sides  of  it.  Only  about  an  inch  of  the  tube 
should  project  into  the  bladder,  just  sufficient  for  the  side 
nings  to  lie  completely  within  its  cavity.  When  the 
bladder  is  allowed  to  contract,  the  tube  is  gripped  by  the 
suprapubic  wound  therein,  so  that  the  whole  of  the  urine 
escapes  through  the  tube.  In  this  way  infection  of  the 
loose  tissues  in  the  prevesical  space  is  obviated,  and  cellulitis 


Fig.  30.— Suprapubic  Drainage-tube.    Actual  Sizk. 

prevented.  On  no  account  should  the  tube  be  inserted  into 
the  prostatic  cavity,  our  object  being  to  facilitate  by  every 
means  the  contraction  of  this  cavity.  If  more  than  an  inch 
of  the  tubing  be  introduced  into  the  bladder,  it  will  press  on 
its  base  and  give  rise  to  constant  straining,  and  pain  in  the 
end  of  the  penis  like  that  caused  by  vesical  stone. 

The  edges  of  the  parietal  wound  arc  now  brought  together 
around  the  tube  by  silk-worm  gut  sutures,  our  or  two  of 
which  should  pass  deeply  through  the  recti  muscles.  On  no 
account  should  buried  sutures  be  employed,  a>  they  are 
tin  to  be  infected  by  the  urine.  One  of  the  sutures 
should  pass  through  the  drainage-tube  to  keep  it  securely  in 
position.     No  sutures  are  inserted  in  the  bladder. 

Before  withdrawing  the  catheter  and  applying  the  dn 
ings  the  bladder  is  once  more  irrigated,  in  order  to  rem 


74         THE  AFTER-TREATMENT  OF  PROSTATECTOMY 

clots  and  ascertain  that  drainage  is  quite  free.  Finally  a 
couple  of  inches  of  broad  iodoform-gauze  tape  are  inserted 
in  one  angle  of  the  wound  against  the  side  of  the  tube,  and 
left  there  for  twenty-four  hours.  This  is  done  for  the  purpose 
of  preventing  the  accumulation  of  fluids  in  the  prevesical 
space.  The  wound  is  now  covered  with  cyanide  of  zinc 
gauze  and  the  patient  deeply  swathed  in  absorbent  dressings 
— front,  sides,  and  back.  The  whole  dressing  is  kept  in 
place  by  a  broad  flannel  binder  or  many-tailed  bandage, 
loosely  applied.  Cotton-wool,  wood-wool  tissue,  or  cellulose 
may  be  employed.  The  last  is  most  absorbent  and  keeps  the 
patient  driest ;  but  a  thin  layer  of  cotton-wool  should  be 
placed  between  it  and  the  skin  ;  otherwise  the  cellulose, 
when  wet,  forms  a  pulp,  which  adheres  to  the  skin  and  feels 
cold  and  clammy.  The  dressings  should  be  changed  when 
saturated  with  urine,  every  four  or  six  hours,  according  to 
the  quantity  of  fluid  secreted.  During  the  first  twenty-four 
hours  after  operation  there  will  generally  be  some  clots  of 
blood  lying  in  the  drainage-tube  ;  these  should  be  removed 
by  long  slender  forceps  at  each  dressing. 

The  bladder  should  be  irrigated  once  daily  by  the  surgeon 
himself,  with  warm  boracic  lotion  or  a  weak  solution  of 
permanganate  of  potash.  For  this  purpose  a  long  glass 
nozzle  attached  to  the  rubber-tubing  of  an  irrigating-can  is 
best,  the  nozzle  being  introduced  through  the  drainage-tube. 
During  the  first  few  days  there  should  be  very  little  pressure 
of  fluid  on  the  bladder,  the  irrigating-can  being  held,  or 
placed  on  a  table,  a  little  above  the  level  of  the  patient's 
abdomen,  so  that  the  lotion  flows  into  the  bladder  and  out 
again  through  the  drainage-tube  with  very  little  force.  It  is 
all-important  that  in  the  early  days  the  drainage  should  be 
thoroughly  free,  and  that  no  pressure  should  be  thrown  on 
the  cavity  from  which  the  prostate  has  been  removed,  either 
by  the  accumulation  of  urine  in  the  bladder  or  by  pressure 


THE  A FTER- TREA  TMENT  OF  PROSTA  TECTOMY        7 5 

from  a  high  column  of  lotion,  so  that  the  cavity  may  remain 
at  rest,  and  that  blood-clot  adherent  to  its  surface  may  be 
undisturbed,  thus  obviating  bleeding  and  facilitating  the 
healing  process.  This  is  the  main  object  with  which  I 
employ  such  a  stout  drainage-tube — that  the  urine  and  clots 
may  escape  through  it  freely,  and  that,  consequently,  there 
may  be  no  straining,  which  would  have  the  effect  of  dilating 
the  cavity.  Patients  who  pass  no  urine  per  urethram  for 
ten  or  twelve  days  after  operation  almost  invariably  do 
best. 

The  patient  should  lie  on  his  back  for  twenty-four  hours, 
after  which  he  should  be  placed  alternately  on  either  side, 
and  on  his  back.  During  the  first  four  or  five  days  he 
should  not  be  allowed  to  make  any  exertion,  all  movements 
being  effected  by  nurses.  Should  there  be  any  oozing  of 
blood  after  the  operation,  the  foot  of  the  bed  should  be 
raised  on  blocks,  and  hypodermic  injections  of  ergotin  given. 
I  have  seen  no  haemorrhage  requiring  more  active  measures 
in  connection  with  this  operation.  Shock,  when  it  occurs 
immediately  after  operation,  should  be  treated  by  warmth 
from  hot-water  bottles,  extra  clothing,  hypodermic  injections 
of  strychnia,  and  enemata  of  coffee  and  brandy.  Pain  or 
spasms  of  the  bladder  should  be  relieved  by  hypodermic 
injections  of  morphia.  Should  there  be  any  bronchial 
catarrh  or  other  lung-affection,  the  patient's  head  and 
shoulders  should  be  well  raised  by  pillows  alter  the  first 
twenty-four  hours  succeeding  the  operation.  And  in  any 
this  position  should  be  encourged  early,  so  as  to  obviate 
hypostatic  congestion  oi  the  lungs. 

As  a  rule  I  remove  the  tube  four  days  after  operation.  If 
the  patient  be  thin  the  tube  may  be  dispensed  with  in  three 
days;  if  he  be  verj  stout  it  should  be  left  in  for  five  days.  Bj 
this  time  plastic  lymph  will  have  been  thrown  out  round  the 
tube,  thus  shutting  off  the  prevesical  space  from  contact  with 


76  THE  AFTER-TREATMENT  OF  PROSTATECTOMY 

the  urine,  and  in  this  way  avoiding  the  occurrence  of  cellu- 
litis :  and  a  free  opening  will  have  been  established  down  to 
the  bladder,  the  wound  in  which  may  now  be  allowed  to 
close  as  rapidly  as  nature  can  accomplish  this  by  granula- 
tion. The  sutures  are  removed  on  the  seventh  or  eight  day, 
by  which  time  primary  union  will  have  taken  place  in  the 
parietal  wound,  save,  of  course,  in  the  track  of  the 
tube. 

Irrigation  of  the  bladder  must  be  continued  daily — twice 
daily,  if  the  urine  be  at  all  foul — by  inserting  the  long  glass 
nozzle  of  the  irrigator  through  the  fistula  right  down  into  the 
viscus.  The  return  stream  will  in  the  early  days  flow  out 
beside  the  nozzle ;  but  as  the  fistula  contracts  the  nozzle  will 
fill  it ;  and  the  irrigation  is  then  accomplished  by  alterna- 
tively filling  the  bladder  with  the  lotion  and  then  withdraw- 
ing the  nozzle,  when  the  fluid  will  rush  out  with  more  or 
less  force.  As  the  case  advances  more  and  more  pressure  on 
the  bladder  may  be  employed.  The  irrigation  should  be 
continued  till  the  boracic  lotion  returns  quite  clear,  or  the 
permanganate  lotion  unaltered.  After  nine  or  ten  days  from 
the  operation  Janet's  method  of  irrigation  may  be  employed, 
if  possible.  This  consists  in  introducing  the  glass  nozzle  into 
the  urethra  and  gradually  raising  the  irrigating-can  till  the 
column  of  fluid  forces  the  lotion  into  the  bladder  and  out 
through  the  suprapubic  opening.  This  is,  perhaps,  the  best 
method  of  flushing  out  the  bladder ;  but  some  patients  will 
not  tolerate  it,  owing  to  the  pain  produced.  It  should  never 
be  employed  during  the  first  week  after  operation  for  fear  of 
causing  bleeding ;  and  if  it  cause  pain  it  should  not  be 
employed  at  all.  Patients  vary  much  in  their  tolerance  of 
this  method  of  irrigation. 

After  a  fortnight  or  so,  when  the  bladder  is  distended  by 
lotion  through  the  nozzle  placed  in  the  suprapubic  opening^ 
the  patient  will    frequently  pass  the  lotion  per  uvdhram  as 


THE  AFTER- TEE. I  TMENT  OF  PROSTA  TECTOMY         77 

rapidly  as  it  enters  the  bladder.     When  this  takes  place,  it 
is  an  effectual  method  of  flushing  out  the  bladder. 

It  will  be  observed  that  I  have  not  hitherto  referred  to  the 
employment  of  the  catheter  for  the  purpose  of  washing  out 
the  bladder  during  the  after-treatment.  In  the  early  days  after 
the  introduction  of  this  operation  I  was  in  the  habit,  as  will 
appear  from  my  previous  lectures,  of  introducing  a  large- 
sized  gum-elastic  catheter  through  the  urethra  daily  after  the 
third  or  fourth  day  from  the  operation,  and  irrigating  the 
bladder  through  this.  The  catheter  was  introduced  partly 
in  consequence  of  my  apprehension  that,  if  it  were  not  thus 
employed,  there  might  be  contraction  of  the  deep  urethra 
during  healing  of  the  prostatic  cavity.  Experience  has, 
however,  taught  me  that  my  apprehension  in  this  respect 
was  quite  unfounded,  for  in  not  a  single  instance  has  there 
been  any  contraction  to  interfere  with  the  free  flow  of  urine. 
I  do  not  now  introduce  a  catheter  till  the  suprapubic  fistula 
has  contracted  to  such  narrow  dimension  that  it  will  not 
admit  the  nozzle,  so  that  irrigation  cannot  be  practised  in 
this  way.  It  is  employed  only  during  the  few  days  before 
the  patient  begins  to  pass  urine  per  urethram  in  volume,  in 
order  to  keep  the  bladder  clean  during  this  transition  period. 
When  once  natural  micturition  is  established,  the  bladder  is, 
of  course,  automatically  flushed  out. 

The  management  of  the  bowels  is  of  the  utmost  impor- 
tance. For  three  or  four  days  previous  to  the  operation  the 
bowels  should  be  tmly  moved  once  daily  at  least,  by  m< 
of  a  laxative  pill  given  at  night  and  a  mild  saline  in  the 
morning.  ( )n  the  morning  ol  the  operation  the  lower  bowel 
should  be  emptied  by  means  of  an  enema.  The  bowels 
should  then  be  left  undisturbed  for  two  or  three  days,  when 
they  should  be  freely  moved  by  castor-oil  or  Liquorice  powder 
— or  any  drug  which  can  be  depended  on  to  act  with  cer- 
tainty and  efficiency.    After  this  the  bowels  should  be  movi  d 


78         THE  AFTER-TREATMENT  OF  PROSTATECTOMY 

gently  once  a  day  by  means  of  a  pill  taken  at  night  or  a 
saline  in  the  morning,  or  both  if  necessary.  Patients  of  the 
prostatic  age  confined  to  bed  are  liable  to  the  accumulation 
of  faeces  in  the  rectum,  forming  a  hard  mass,  owing  to  the 
want  of  tone  in  the  bowel.  The  occurrence  of  this  is  attended 
by  much  discomfort  and  spasm  of  the  bladder  from  pressure 
thereon,  and  this  must  be  guarded  against.  Should  its 
presence  be  suspected,  a  finger  should  be  introduced  into  the 
rectum,  the  mass  broken  down,  and  removed  by  an  enema 
of  warm  olive-oil. 

Patients  should,  as  a  rule,  be  confined  to  their  room,  but 
not  necessarily  kept  in  bed,  for  three  or  four  days  before  the 
operation.  Poor,  broken-down  hospital  patients  will  require 
to  be  kept  under  observation  for  several  days  at  least,  in 
order  that  they  may  be  fed  up,  and  their  general  health 
improved  before  operation. 

I  have  entered  somewhat  at  length  into  the  details  of  the 
after-treatment,  because  I  consider  that  an  intelligent  appre- 
ciation of,  and  attention  to,  them  is  not  less  essential  to 
success  than  the  skilful  performance  of  the  operation. 

Secondary  Haemorrhage. 

Secondary  haemorrhage  has  occurred  in  a  few  instances. 
It  is  a  very  rare  sequela  of  the  operation,  but  has  to  be 
dealt  with  occasionally. 

Slight  arterial  haemorrhage  may  occur  from  the  supra- 
pubic wound  on  removal  of  the  large  drainage-tube  on  the 
fourth  or  fifth  day.  This  is  purely  traumatic  and  due  to  the 
fact  that  the  tube  is  gripped  by  the  bladder.  The  utmost 
gentleness  should  be  employed  in  removing  the  tube,  which 
should  be  withdrawn  slowly,  and  with  a  slight  rotatory 
movement,  should  it  be  gripped  very  tightly  by  the  wound. 
The  bleeding  from  this  cause  is  always  trifling,  and  auto- 
matically ceases  in  a  short  time. 


THE  AFTER-TREATMENT  OF  PROSTATECTOMY  79 

Should  there  be  any  obstruction  to  the  free  flow  of  the 
contents  of  the  bladder  through  the  tube  during  the  early 
days  after  operation,  the  prostatic  cavity  is  liable  to  be 
dilated,  resulting  possibly  in  venous  haemorrhage  from  its 
walls.  This  is  controlled  by  readjusting  the  tube  in  such  a 
manner  that  a  free  outlet  is  gained  to  the  urine,  and  by 
irrigating  the  bladder  through  the  tube  with  boracic  lotion 
as  hot  as  the  patient  can  bear. 

But  the  most  serious  form  of  haemorrhage  takes  place, 
strange  to  say,  in  the  case  of  patients  in  whom  the 
healing  process  is  most  rapid,  resulting  in  the  suprapubic 
wound  closing  earlier  than  usual.  Urine  is  then  passed 
per  urethram  before  the  prostatic  wound  is  sufficiently  .healed 
to  bear  the  resultant  pressure  on  its  surface,  and  haemorrhage 
may  take  place  owing  to  spasm  of  the  bladder  and  the 
consequent  undue  pressure  on  the  prostatic  cavity.  Should 
this  occur,  a  full-sized  rubber  or  gum-elastic  catheter  should 
be  introduced  through  the  urethra  and  tied  in  the  bladder, 
so  as  to  give  free  exit  to  its  contents. 

But  should  the  haemorrhage  persist,  giving  rise  to  pain 
and  spasm  from  the  accumulation  of  clots  in  the  bladder,  no 
time  should  be  lost  in  reopening  the  suprapubic  wound,  and 
in  reinserting  a  large  drainage-tube  for  a  few  days,  to  relieve 
the  pressure  on  the  walls  of  the  prostatic  cavity.  Hypoder- 
mic injections  of  ergotin  and  the  administration  by  the 
mouth  of  calcium  chloride  should  also  be  employed.  The 
following  is  an  illustrative  case  of  secondary  haemorrhage 
from  this  cause,  and  the  method  of  dealing  therewith. 

Case  185.  Gentleman,  aged  fifty-seven,  seen  with  Mr.  E.  I'.  Madge, 
London,  May  5,  1^05.  Prostatic  symptoms  for  seven  years  ;  complete 
retention  ot  urine  in  August,  1^04;  relieved  by  catheter,  which  had 
employed  for  some  weeks,  duririg  which  patient  was  laul  up  in  bed  with 
cystitis.  Since  this  several  atta<  ks  of  pyrexia  from  urinary  sepsis.  Much 
blood  in  urine  a  fortnight  ago-  I  introduced  a  catheter,  and  drew  off 
8  ounces  residual   urine,  acid,   specific   gravity    1012,   containing    pus. 


So  THE  AFTER-TREATMENT  OF  PROSTATECTOMY 

Prostate  much  enlarged,  bilobed,  smooth,  soft,  movable,  easily  felt 
bimanually.     General  health  fair. 

On  May  15,  Mr.  Madge  being  present,  I  enucleated  the  prostate, 
weighing  2  ounces,  entire  in  its  capsule,  the  time  occupied  being  three 
and  a  half  minutes  ;  scarcely  any  bleeding  or  shock.  During  the  first 
fortnight  there  was  not  an  unfavourable  symptom  ;  in  fact,  healing  was 
more  rapid  than  usual,  urine  being  passed  freely  per  urethram  May  26, 
and  the  suprapubic  wound  being  dry  next  day.  On  May  29,  whilst 
straining  at  stool,  some  blood  was  passed  in  the  urine,  and  this  continued 
off  and  on  for  some  days.  The  tying  in  of  a  soft  catheter  temporarily 
relieved  the  bleeding ;  but  on  June  3  large  clots  blocked  the  catheter,  and 
there  was  much  painful  spasm  and  straining  in  spite  of  repeated  washing 
out  of  the  clots.  I  therefore  reopened  the  suprapubic  wound,  which  was 
firmly  healed,  under  an  anaesthetic,  and  inserted  a  large-sized  drainage- 
tube.  After  this  bleeding  entirely  ceased.  The  tube  was  removed  after 
a  week.  On  June  14  the  suprapubic  wound  was  quite  healed,  and  all  the 
urine  passed  naturally. 

On  June  24  patient  left  the  surgical  home,  passing  and  retaining  his 
urine  as  well  as  he  ever  did,  and  he  is  now  in  excellent  health. 


LECTURE  V 

THE  SCOPE  AND  LIMITS  OF    THE  OPERATION  OF    TOTAL 
ENUCLEATION  OF  THE  PROSTATE 

In  the  lectures  and  papers  published  by  me  from  time  to 
time  during  the  past  four  and  a  half  years  I  have  given  full 
details  of  most  of  my  first  206  cases  of  this  operation.  In 
each  instance  I  have  described  the  physical  characteristics 
which  the  prostate  presented  before  operation,  as  ascertained 
on  examination :  (1)  By  the  finger  introduced  into  the 
rectum  ;  (2)  bimanually  ;  and  (3)  in  many  instances  by  the 
cystoscope. 

I  have,  however,  hitherto  refrained  from  placing  before 
the  profession  at  large*  a  comprehensive  classification  of  ca 
suitable  for  the  operation.  I  have  done  so  designedly  till 
I  should  have  acquired  experience  derived  from  a  sufficiently 
large  number  of  cases  to  make  the  classification  more  or  less 
exhaustive  and  practical  :  for  as  time  has  gone  on  1  have 
been  gradually  extending  the  scope  of  the  operation.  I  feel 
that  now,  with  the  accumulated  experience  derived  bom 
over  30*  of  the  operation,  I  am  in  a  position  to  answer 

a  question  that  is  frequently  put  to  me:  In  what  class  "i 
cases  of  enlargement  <>t  the  prostate  is  total  enucleation  ol 
the  organ  indicated  ? 

*  The  substance  of  this  lecture  was  embodied  in  t he  opening  add 
foi  the  session  [904-1905  of  the  Oxford  Medical  Society,  which  I  hadthe 
honour  of  delivering,  but  which  has  never  been  published. 

81  6 


2,2  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

Now,  this  is  a  question  which  cannot  be  answered  off-hand. 
In  arriving  at  a  classification  of  cases  suitable  for  the  opera- 
tion, apart  from  the  patient's  age  and  general  state  of  health, 
the  following  special  considerations  have  to  be  taken  into 
account,  (i)  The  specific  symptoms  dependent  on  the 
prostatic  enlargement ;  and  (2)  the  nature,  size,  and  general 
conformation  of  the  prostatic  growth. 

I.  The  various  types  of  patient  suffering  from  prostatic 
symptoms  that  apply  for  surgical  relief  may  be  classified 
thus : 

1.  Patients  suffering  from  the  usual  symptoms  of  enlarged 
prostate  in  the  earlier  stages  of  the  malady,  in  whom  not 
more  than  an  ounce  or  two  of  residual  urine  is  found  on 
introducing  the  catheter. 

2.  Those  who  have  probably  suffered  from  prostatic 
symptoms  for  several  years,  in  which  we  detect  a  quantity 
of  residual  urine  varying  from  3  to  10  ounces,  or  even  more, 
but  who  have  never  employed  a  catheter  for  the  purpose  of 
emptying  the  bladder. 

3.  Those  suffering  from  over-distension  of  the  bladder, 
with  great  frequency  of  micturition,  possibly  continuous 
dribbling  of  urine,  but  who  have  never  been  relieved  by  a 
catheter. 

4.  Patients  in  whom  the  conditions  described  in  para- 
graph (3)  have  culminated  recently  in  complete  retention  of 
urine,  and  in  whom  great  difficulty  is  experienced  in  intro- 
ducing a  catheter. 

5.  Patients,  who  from  time  to  time  have  had  retention  of 
urine,  which  was  relieved  by  catheter,  but  who  have  not 
employed  the  instrument  as  a  routine  practice  to  empty  the 
bladder  daily. 

6.  Those  who  for  weeks,  months,  or  years  have  daily 
emptied  the  bladder  by  the  catheter,  once,  twice,  or  oftener, 
but  who  can  pass  more  or  less  urine  naturally. 


TOTAL  ENUCLEATION  OF  THE  PROSTATE  83 

7.  Those  entirely  dependent  on  the  catheter,  and  who,  in 
the  advanced  stages  of  the  disease,  will  probably  have 
suffered  from  one  or  more  of  the  following  complications — 
viz.,  cystitis,  haemorrhage,  vesical  calculus,  rigors  with  fever, 
and  difficulty  in  introducing  the  instrument. 

In  the  first  of  these  types  it  will,  as  a  rule,  be  unnecessary 
and  inadvisable  to  attempt  the  removal  of  the  prostate, 
because  the  enlargement  of  the  organ  will  not  have  sufficiently 
advanced  to  render  it  prominent  in  the  bladder,  or  to  define 
adequately  the  lines  of  cleavage  between  the  true  capsule  of 
the  prostate  and  its  enveloping  sheath.  But  in  one  and  all 
the  other  types  the  removal  of  the  prostate  should  be  enter- 
tained and  advocated  if  on  examination  it  presents  those 
characteristics — to  be  presently  described — that  render  its 
enucleation  entire  in  its  capsule  practicable,  there  being  no 
condition  in  the  general  health  of  the  patient  to  bar  an 
operation  of  this  magnitude. 

II.  To  ascertain  whether  the  prostate  is  one  capable  of 
being  enucleated  entire,  the  patient,  if  capable  of  passing 
anv  urine  naturally,  is  directed  to  empty  his  bladder  as  far 
as  possible,  and  is  then  placed  on  a  couch  in  the  recumbent 
position.  The  bladder  is  now  emptied  of  its  residual  urine 
by  the  aid  of  a  catheter,  ami  the  quantity  <>f  residual  urine 
noted.  The  forefinger  of  one  hand,  previously  lubricated,  is 
slowlv  introduced  into  the  rectum,  and,  when  the  sphincter 
ani  is  thoroughly  relaxed,  a  survey  of  the  rectal  aspect  of  the 
prostate  is  made.  If  the  organ  is  found  to  be  decidedly 
enlarged,  presenting  a  well-marked  tumour  in  the  rectum, 
more  or  less  rounded  in  shape,  latterly  bilobed  with  a  well- 
marked  groove  or  furrow  in  the  median  line  smooth  on  the 
Surface,  soft  and  SOmewhal  dense  and  elastic  to  the  touch, 
and,    most    important    of    all.    movable,   you    know   that    you 

have  to  deal  with  the  ordinary  adenomatous  enlargement  oi 

tlu'  gland  of  advanced  life.     If,  in  addition,  from  its  promi- 

2 


84  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

nence  in  the  rectum  you  estimate  this  tumour  to  be  at  least 
the  size  of  a  Tangerine  orange,  the  case  may  be  regarded  as, 
in  all  probability,  one  in  which  the  prostate  is  capable  of 
being  enucleated  entire. 

We  next  proceed  to  make  a  bimanual  examination  of  the 
prostate.  This  is  accomplished  by  placing  the  fingers  of  the 
unoccupied  hand  on  the  hypogastrium,  and  pressing  them 
well  down  immediately  behind  the  pubic  arch,  directing  the 
patient  at  the  same  time  to  relax  the  abdominal  muscles. 
Counter-pressure  is  made  by  the  finger  in  the  rectum.  If 
the  prostate  be  decidedly  enlarged  it  will  be  felt  between  the 
fingers  of  the  two  hands,  and  can  be  slightly  moved  about, 
upwards,  downwards,  and  from  side  to  side,  somewhat  like 
a  chronically-enlarged  uterus.  If  it  be  very  prominent  in 
the  bladder,  the  outgrowth  in  that  viscus  will  be  easily 
recognised,  and  in  thin  subjects  the  origin  of  this  outgrowth, 
whether  from  the  right  or  left  lobe,  or  from  both.  In  thin 
or  moderately  stout  patients  this  method  of  examination 
is  easily  accomplished,  and  is  most  helpful  for  diagnostic 
purposes.  In  very  stout  subjects  it  is  unsatisfactory. 
Occasionally  we  meet  with  patients  who  cannot  relax  their 
abdominal  muscles.  In  such  cases  the  examination  can 
only  be  satisfactorily  accomplished  under  the  influence  of  an 
anaesthetic. 

If  on  bimanual  examination  the  prostate,  with  the  charac- 
teristics already  described,  be  felt  distinctly,  we  can  at  once 
conclude  that  the  case  is  one  in  which  the  organ  can  be 
enucleated  entire  in  its  capsule,  no  matter  to  what  magnitude 
it  may  have  attained.  Prostates  weighing  from,  say,  about 
2  to  6  ounces,  are  those  most  easily  and  rapidly  enucleated, 
as  the  following  cases  will  illustrate  : 

Case  49. — ( jentleman,  aged  sixty-three,  first  consulted  me  November  29, 
1902,  on  the  advice  of  Dr.  Fennings  of  St.  Leonards-on-Sea.  Prostatic 
symptoms  for  ten  years.     Catheter  employed  for  six  months.     Much  pain,. 


TOTAL  ENUCLEATION  OF  THE  PROSTATE 


35 


great  frequency  of  micturition  and  straining,  causing  involuntary  actions 
of  the  bowels.  Very  feeble  constitution  :  suffering  from  bad  asthma  and 
bronchitis.  Prostate  much  enlarged  per  rectum,  bilobed,  soft,  elastic,  and 
movable.  The  case  was  regarded  as  a  suitable  one  for  operation,  but 
postponement  was  advised  till  patient  should  get  rid  of  the  bronchitis, 
which  he  never  did  in  winter. 

Saw  patient  again  in  May,  1903,  when  the  bronchitis  had  disappeared, 
but  the  asthma  was  as  bad  as  ever.     The  prostatic  symptoms  had  much 


Fig.  31.     Prostai  e,  weighing  3 \  Oi  nces,  ri  moved  from  Patient 

aged  Sixty-three  (Case  49).    .\<  n  \i.  Size. 
a,  Righl  lobe  ;  B,  left  lobe,  presenting  .1  projection,  <  .  into  the  bladder. 

the  so-i  ailed  '  middle  lobe.'      I  he  1  athetei  shows  the  tortuous  course 

of  the  urethra. 


1  ed.      Catheter  required  three  times  daily;  residual  urine,  8   to 
10  ouni  es,  1  ontaining  mm  h  pus. 

On  Jum  ii   Joseph   Fayrer  and  Mr.  Walsham  being  present, 

l  removed  the  prostate  entire  in  its  capsule,  leaving  the  urethra  behind. 
'1  lie  p. iti. m  was  only  eighteen  minutes  on  the  operating  table,  and  the 
tim<     0  cupied    from   commencing    the   suprapubic   cystotomy   till    the 


86  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

prostate  was  delivered  from  the  bladder  was  five  minutes.  Scarcely  any 
bleeding  and  no  shock.  The  patient  began  to  pass  urine  naturally 
June  20,  though  the  fistula  was  somewhat  slow  in  closing.  He  is  now  in 
excellent  health,  untroubled  by  any  urinary  symptom. 

The  prostate  (Fig.  31),  which  weighs  2>i  ounces,  is  a  most  interesting 
specimen,  presenting  an  irregularly-curved  outgrowth  of  the  left  lobe  in 
the  bladder  (the  so-called  '  middle  lobe '),  which  acted  as  a  ball-valve  to 
the  inner  orifice  of  the  urethra. 

Case  53. — Gentleman,  aged  seventy-four,  sent  by  Dr.  J.  Williamson, 
Richmond,  July  22,  1903,  with  prostatic  symptoms  of  seven  years' 
duration.  Retention  a  fortnight  previously,  and  no  urine  since  then 
passed  naturally.     Owing  to  impossibility  of  introducing  the  catheter, 


Fig.  32. — Prostate,  Weighing  i|  Ounces,  removed  from  Patient 
aged  Seventy-four  (Case  53). 

a,  Right  lobe,  contained  a  nipple-shaped  projection,  C,  in  the  bladder  ; 

];,  left  lobe. 

bladder  tapped  suprapubically  a  week  before.  Patient  very  thin  and  in 
feeble  health.  Urine  contains  much  pus  and  blood.  Prostate  enlarged 
per  rectum,  soft,  smooth,  movable. 

On  July  24,  Dr.  Williamson,  Mr.  Boyce  Barrow,  Major  J.  F.  Blood, 
and  others  being  present,  I  removed  the  prostate  entire  in  its  capsule, 
leaving  the  urethra  behind,  the  time  occupied  from  commencing  the 
operation  till  the  prostate  was  delivered  from  the  bladder  being  only  two 
minutes.  There  was  very  little  bleeding  and  no  shock.  The  patient 
recovered  without  any  unfavourable  symptom.  On  March  19,  1906,  he 
wrote  :  '  I  never  cease  to  think  of  you,  and  at  night  to  bless  you,  for  such 
a  restoration — as  perfect  as  can  be.' 


TOTAL  ENUCLEATION  OF  THE  PROSTATE  87 

The  prostate  (Fig.  32),  which  weighs  1^  ounces,  presents  a  well-marked 
so-called  'middle  lobe,'  which  is  merely  an  outgrowth  of  the  right  lobe  in 
the  bladder. 

Case  112. — A  gentleman,  aged  sixty-two,  consulted  me  on  June  29, 
1904,  on  the  advice  of  Dr.  R.  G.  Pollock,  Tiverton.  Prostatic  symptoms 
for  three  years.     Retention  of  urine  two  years  previously  and  on  several 


Fig.  J3. — Prostate,  weighing  6?  Cm  nces,  removj  Patient 

\(,i  i.  Six  n  rwo  (C  vse  112). 

\,  Left  lobe;  B,  right  lobe,  giving  oflf  an  outgrowth,  c,  in  the  bladder. 
Catheter  shows  tortuou  >i  urethra. 

ions  within  the   next  \  by  catheter.     Dependent  on 

catheter  for  one  yen.     Repeated  r<  hitis, and  hemor- 

rhage, with  clots  blocking  1 1 1  *  -  catheter;  much  pain.     Prostate  greatly 
enlarged  per  rectum,  bilobed,  smooth,  ten  .  movable.     Easily 


TOTAL  ENUCLEATION  OF  THE  PROSTATE 


felt  bimanually  ;  the  size  and  shape  of  a  large  pear.     Urine  contained 
pus,  blood,  and  albumin.     Patient  very  stout  ;  general  health  fair. 

On  July  4,  Lieut. -Colonel  D.  ffrench-Mullen,  I. M.S.,  and  Dr.  Laing 
Gordon,  of  Florence,  being  present,  I  enucleated  the  prostate  entire  in 
its  capsule,  leaving  the  urethra  behind.  Time  from  commencing  the 
operation  till  the  prostate  was  delivered  from  the  bladder,  six  minutes. 
More  bleeding  than  usual,  but  no  shock;  uninterrupted  recovery.  Passed 
some  urine  naturally  on  July  22  ;  wound  closed  on  July  26.  Went  home 
in  good  health  on  August  5  ;  able  to  pass  and  to  retain  his  urine,  which 
was  normal,  as  well  as  he  ever  did.     On  March  6,  1906,  he  writes  :   '  I 


Fig.  34.— Prostate,  weighing  \\  Ounces,  removed  from  Patient 

aged  Sixty-seven  (Case  133). 

A,  Left  lobe  ;   B,  right  lobe. 

am  able  to  retain  and  pass  urine  without  any  difficulty;  and  I  now  turn 
the  scale  at  212  pounds,  which  is  heavier  than  I  have  ever  been  before.' 

The  prostate  (Fig.  33),  which  weighs  6jj  ounces,  is  a  fine  specimen  of 
symmetrical  adenomatous  enlargement.  Two-thirds  of  the  prostate  pro- 
jected into  the  bladder. 

Case  133. — J.  N ,  aged  sixty-seven,  sent  by  Dr.  Duckworth  Barker, 

Bexhill,  admitted  to  St.  Peter's  Hospital,  October  4,  1904,  for  prostatic 
symptoms  of  four  years'  duration.  Had  retention  of  urine  on  four 
occasions;  relieved  by  catheter.  Residual  urine,  8  ounces,  containing 
some  pus  and  albumin.    Had  '  a  stroke ;  three  months  previously,  affecting 


TOTAL  ENUCLEATION  OF  THE  PROSTATE 


So 


the  whole  of  left  side  and  speech,  from  which  he  had  only  partially 
recovered.  Prostate  felt  enlarged  per  rectum,  bilobed,  smooth,  soft, 
movable;  bimanually  felt  to  be  size  of  a  Tangerine  orange. 

On  October  12  I  had  the  honour  of  operating  in  presence  of  Professors 
Poirier,  Hartmann,  Lucas-Championniere,  Reynier,  Proust,  and  many 
other  distinguished  French  surgeons  during  their  visit  to  London.     The 


Fig.  o     Pri  >-i  vi  e,  weighing  3;  Ounces,  removed  from  Patieni 
\.ged  Sixty-seven  (Casi    i 

a,  Right  lobe,  terminating  in  bladder  in  the  outgrowth,  C,  so-called 
•  middle  '  lobe  :  B,  left  lobe. 


prostate  Fig.  34)  was  easil;  and  rapidly  enucleated  entire  in  its  capsule, 
the  urethra  behind  the  verumontanum  coming  away  with  it.  the  time 
occupied  from  commencing  the  operation  till  the  prostate  was  delivered 
from  the  bladder  being  three  minutes.  Scarcely  any  bleeding  or  .slunk. 
The  prostate,  which  was  symmetrically  enlarged,  weighed  1  |  ounces. 
Uninterrupted  recovery,  some  urine  passing  naturally  Novembi 
and   the  wound   being  dry    November  4.      Patient    returned   home   quite 


90  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

well  November  25,  passing  and  retaining  his  urine  as  well  as  ever  he  did. 
On  January  20,  1905,  Dr.  Barker  wrote  :  '  The  operation  has  been  a  great 
success.  He  can  hold  his  water  all  night  with  comfort,  and  can  go  for 
four  to  six  hours  during  the  day  without  any  difficulty.'  On  March  5, 
1905,  the  patient  wrote  :   '  I  am  keeping  perfectly  well.' 

Case  193. — This  gentleman,  aged  sixty-seven,  who  had  come  from 
California  on  the  advice  of  Dr.  Tom  Davis,  Los  Angeles,  for  the  purpose 
of  having  his  prostate  removed,  consulted  me  on  May  3 1 ,  1905.  Prostatic 
symptoms  had  existed  fifteen  years.  Retention  of  urine  six  years  ago, 
since  when  he  has  employed  the  catheter  ;  entirely  dependent  thereon 
four  years.  Has  had  repeated  attacks  of  cystitis,  and  latterly  difficulty  in 
introducing  the  catheter.  The  prostate  was  much  enlarged  per  rectum, 
bilobed,  smooth,  soft,  movable  ;  easily  felt  bimanually,  being  very 
prominent  in  the  bladder.     General  health  fair  ;  thin,  but  wiry. 

On  June  5,  in  the  presence  of  Professor  J.  Kaarsberg  and  Drs.  A. 
Helsted  and  A.  F.  Just,  of  Copenhagen,  I  removed  the  prostate  entire  in 
its  capsule  rapidly  and  easily,  the  time  from  commencing  the  suprapubic 
incision  till  the  prostate  was  delivered  from  the  bladder  being  three 
minutes.     There  was  practically  no  bleeding  and  no  shock. 

The  recovery  was  uneventful,  some  urine  being  passed  naturally  on 
June  16,  and  entirely  in  this  way  after  June  22.  By  June  29  he  was 
walking  about,  passing  and  retaining  urine,  which  was  quite  clear,  as  well 
as  he  ever  did.  Writing  from  California  on  November  19,  1905,  his  wife 
says  :  '  My  husband  is  perfectly  well  and  completely  cured.  He  has  not 
had  the  slightest  trouble  since  he  left  the  home.  He  goes  to  bed  about 
ten  o'clock,  and  is  not  disturbed  till  seven  or  eight  in  the  morning.' 

The  prostate  (Fig.  35),  which  weighs  3^  ounces,  is  an  interesting 
specimen,  displaying  a  large  so-called  'middle'  lobe  (c)  the  size  of  a 
Tangerine  orange,  growing  mainly  from  the  right  lobe.  This  portion, 
which  lay  entirely  in  the  bladder,  was  merely  covered  by  mucous 
membrane. 

But  prostates  of  larger  sizes  can  be  similarly  dealt  with, 
though  those  attaining  to  enormous  dimensions  present 
considerable  difficulties,  mainly  owing  to  their  being  impacted 
beneath  the  pubic  arch,  and  to  the  difficulty  experienced  in 
reaching  with  the  finger  the  distal  portions  of  the  growth — 
those  in  proximity  to  the  rectum  and  triangular  ligament — 
to  separate  the  capsule  from  the  enveloping  sheath.  I  will 
now  give  details  of  some  instances  of  very  large  prostates 
removed  by  me,  illustrating  the  difficulties  encountered,  and 
the  manner  in  which  these  difficulties  may  be  surmounted. 


Fig.  >rmous  Prostatk,  weighing    roj   Ounces,   removed 

FROM    I'MUNi     v.l-.n    SEVENTY-FIV1    (CAS!     5).      EXA<   I    Si 

shows  the  position  occupied  by  the  urethra.     Portion  \.   \', 
B,  1:',  lay  in  the  bladder,  and  B,  b',  C,  ( '.  lay  outside  the  bladder. 


92  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

Case  5. — This  gentleman,  aged  seventy-five  years,  came  from  France 
for  operation  on  the  advice  of  the  late  Dr.  R.  Cox,  of  Reading,  and 
Dr.  J.  A.  Philip,  of  Boulogne.  Completely  dependent  on  the  catheter  for 
fourteen  years.  Repeated  attacks  of  cystitis  and  hematuria.  Much 
difficulty  in  introducing  the  catheter,  which  latterly  he  had  to  use  every 
half-hour  night  and  day.  A  specially  long  catheter  was  necessary,  from 
14  to  16  inches  being  introduced  before  the  urine  flowed.  The  urine  was 
putrid  from  pus  and  blood,  and  the  patient  was  emaciated  and  in  great 
agony.  As  Dr.  Philip  wrote  :  '  It  was  only  his  fine  constitution  that 
enabled  him  at  his  age  to  survive  a  period  of  martyrdom  which  was 
increasing  in  severity.'  The  prostate  felt  enormously  enlarged  per  rectum, 
and  the  kidneys  were  tender  and  probably  much  affected. 

On  September  6,  1901,  with  Mr.  C.  Braine  as  anaesthetist,  I  removed 
the  entire  prostate  (Fig.  36)  in  its  capsule  in  the  manner  already  described. 
The  operation  lasted  half  an  hour.  There  was  no  collapse,  and  on 
waking  from  the  anaesthetic  the  patient  began  to  laugh  and  joke.  The 
temperature  never  rose  above  ioo°  F.,  and  remained  normal  after 
September  12.  Six  ounces  of  urine  passed  naturally  on  October  7,  and 
the  wound  had  closed  by  the  17th.  On  November  3  he  returned  to 
France.  On  April  14,  1903,  he  wrote:  '  I  am  perfectly  well  with  regard 
to  my  bladder,  and  suffer  no  pain  or  inconvenience  from  it,  and  pass  my 
urine  as  well  as  I  ever  did  before  the  prostate  troubles.'  In  September, 
I9°3?  two  years  after  the  operation,  I  spent  part  of  a  day  with  him  in 
France  ;  he  was  then  in  excellent  health,  and  as  fine  a  man  of  his  age  as 
one  could  meet.  On  May  9,  1906,  he  writes  :  'My  waterworks  are  all 
right,  and  I  feel  as  well  in  that  respect  as  I  ever  did  in  my  life,  and  am 
wonderfully  well  for  my  age.' 

The  prostate  (Fig.  36)  is  an  enormous  one,  weighing  10-J  ounces. 

Case  106. — On  June  4,  1904,  I  was  called  to  Ipswich  to  see,  in  con- 
sultation with  Dr.  Branford  Edwards,  a  gentleman,  aged  seventy-three, 
who  had  suffered  from  prostatic  symptoms  for  over  fifteen  years.  Reten- 
tion of  urine  in  1889  ;  relieved  by  catheter.  Entirely  dependent  on 
catheter  for  ten  years,  during  which  has  had  repeated  attacks  of  acute 
cystitis  and  haemorrhage.  Calculi  crushed  on  three  occasions  by  another 
surgeon,  the  last  being  in  February,  1904,  since  when  the  patient  has 
been  much  worse,  requiring  a  permanent  nurse.  Catheter  used  every 
two  hours  ;  bladder  washed  out  three  times  daily.  Still  urine  very  foul, 
containing  much  pus  and  mucus  and  some  blood.  Much  difficulty  in 
introducing  catheter,  which  passes  in  14  inches  before  the  urine  flows. 
Patient  in  a  very  miserable  condition,  requiring  opiates  to  relieve  pain. 
Prostate  enormously  enlarged  per  rectum,  filling  the  space  between  the 
pubic  arch  and  the  sacrum,  round,  tense,  smooth,  scarcely  movable  owing 
to  its  size.     Examination  gave  much  pain. 


TOTAL  ENUCLEATION  OF  THE  PROSTATE 


93 


On  June   14   I    enucleated  the  prostate  entire   in   its  capsule,  Mr.  C. 
Braine,  anaesthetist,  Drs.  Edwards  and  Brown  of  Ipswich  and  Professor 


Fig.  ',7.    Enormous   Prostate,   weighing   \\\   Ounces,  removed 
from  Patient  aged  Seventy-threi    Casi   io6).    Ai  ruAi  Si  e. 

a,  Left  lobe,  showing  an  ulcer  at  i>.  caused  by  vesica]  calculus  ;  B,  right 
lobe  ;  1  .  sam  er-shaped  lip  connecting  the  lateral  lobes,  and  prominent 
in  bladder. 

Pye  of  Galway  being  present.     On  opening  t lie  bladder  suprapubically 
I  found  both  I"!"     (I  .;.  37,   \  and  b),  enormously  enlarged,  filling 


94  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

cavity.  They  were  more  or  less  symmetrical,  separated  by  a  deep  fissure 
in  front,  continued  forward  to  the  vesical  neck,  and  united  behind  by  a 
thick,  prominent,  scoop-shaped  lip  (c).  I  could  pass  my  finger  down 
behind  the  prostate  between  it  and  the  base  of  bladder  for  a  space  of 
4  inches,  and  in  this  position  lay  much  phosphatic  debris  embedded  in 
thick  muco-pus.  The  prostate  was  enucleated  as  a  whole  into  the  bladder 
after  severe  manual,  or  rather  digital,  labour,  great  difficulty  being 
experienced  in  separating  the  capsule  from  the  sheath  owing  to  the  great 
size  of  the  gland  and  its  being  jammed  between  the  pubic  arch  and 
sacrum,  like  the  fcetal  head  in  parturition.  The  suprapubic  wound  in  the 
bladder  had  to  be  enlarged,  and  the  lobes  separated  by  the  finger  to 
facilitate  delivery  of  the  prostate.  There  was  scarcely  any  bleeding — a 
remarkable  fact  considering  the  enormous  size  of  the  prostate.  There 
was  no  shock,  the  patient  being  cheerful,  even  jocular,  during  the  day. 
Time  occupied  from  commencing  the  suprapubic  wound  till  the  prostate 
was  delivered  from  the  bladder,  fourteen  minutes. 

Recovery  uneventful;  in  fact,  patient  felt  no  ill-effects  after  the 
operation,  the  temperature  remaining  normal  throughout.  Passed 
4  ounces  of  urine  naturally  July  4  ;  wound  closed  July  12.  Went  home 
July  19  in  excellent  health,  able  to  pass  and  retain  his  urine  as  well  as  he 
ever  did.  On  March  4,  1906,  he  wrote  :  '  I  am  perfectly  well.  I  can 
pass  water  with  the  greatest  comfort,  and  can  retain  it  from  three  to  four 
hours.  I  have  perfect  control  over  it.  I  am  really  strong,  and  can  walk 
four  or  five  miles  without  feeling  tired.  I  am  up  to  my  normal  weight  of 
13  stones  2  pounds.  When  I  returned  home  after  the  operation  I  only 
weighed  10  stones  6  pounds.     I  am  leading  a  most  comfortable  life.' 

The  prostate  (Fig.  37)  weighs  14^  ounces,  and  is  the  largest  I  have 
removed.  It  is  a  fine  specimen,  enucleated  complete  in  the  capsule. 
The  lateral  lobes  (a,  b)  are  almost  symmetrical,  and  united  behind  by  a 
thin,  saucer-like  lip  (c),  which  interfered  much  with  the  introduction  of 
the  catheter.  At  D,  the  vesical  end  of  the  left  lobe,  is  an  ulcer,  no  doubt 
caused  by  pressure  of  a  vesical  calculus.  The  labour  involved  in  removal 
of  this  prostate  was  very  severe,  and  my  fingers,  hands,  and  arms  ached 
for  two  or  three  days  owing  to  the  muscular  exertion  necessary. 

Case  165. — Gentleman,  aged  seventy-four,  first  seen  by  me  at  Brixton, 
January  18,  1904,  in  consultation  with  Dr.  A.  D.  Jollye.  Prostatic 
symptoms  had  existed  six  years,  during  which  time  retention  of  urine  had 
frequently  occurred  and  was  relieved  by  the  catheter,  which  was,  how- 
ever, not  habitually  employed.  There  was  intense  pain  and  frequency  of 
micturition,  and  for  two  days  the  urine  had  contained  blood.  The  residual 
urine  only  amounted  to  5  ounces,  but  the  prostate  felt  enormously 
enlarged,  globular,  dense,  smooth,  movable,  and  placed  very  high  up  in 
the  rectum.     Sounded,  but  no  stone  found.     The  patient  being  averse  to 


TOTAL  ENUCLEATION  OF  THE  PROSTATE  95 

operation,  I  advised  the  employment  of  the  catheter  four  or  five  times 
daily. 

I  next  saw  him  January  2,  1905,  when  he  desired  to  have  the  prostate 
removed.  Though  the  catheter  had  been  regularly  employed  five  or  six 
times  daily,  the  symptoms  had  grown  gradually  worse,  so  that  he  was  now 
suffering  from  severe  cystitis,  with  alkaline  urine  containing  much  blood 
and  ropy,  offensive  muco-pus.  The  prostate  was  so  tender  that  he  could 
scarcely  bear  examination  by  the  urethra  or  rectum.  The  patient's 
condition  was  indeed  pitiable,  and,  in  addition  to  the  local  troubles,  he 
had  lost  much  flesh,  though  still  very  stout  ;  his  pulse  was  irregular  and 
intermittent,  and  he  was  suffering  from  chronic  bronchitis,  with  rapid  and 
laboured  breathing.  Under  these  circumstances  I  declined  to  operate 
till  the  bronchitis  should  have  subsided,  probably  during  the  ensuing 
summer  ;  but  on  January  23  he  entered  a  surgical  home  and  begged  for 
operation,  stating  that  he  preferred  any  risk  therefrom  rather  than  employ 
the  catheter  any  longer. 

On  January  26,  Mr.  C.  Braine  being  the  anaesthetist  and  Dr.  [ollye 
assisting,  I  opened  the  bladder  suprapubically,  and  found  a  phosphatic 
calculus  lying  behind  the  prostate.  This  was  removed,  and  weighed 
63  grains.  I  then  proceeded  to  enucleate  the  prostate,  which  was  larger 
than  a  cricket-ball.  The  lobes  were  symmetrically  enlarged,  and  two- 
thirds  of  the  mass  lay  in  the  bladder,  covered  merely  by  mucous 
membrane.  Owing  to  the  stoutness  of  the  patient  and  the  rigidity  of  his 
muscles,  even  under  the  most  profound  anaesthesia,  great  difficulty  was 
experienced  in  reaching  the  distal  aspect  of  the  prostate  to  enucleate  it 
out  of  the  sheath  inwards  the  rectum  and  strip  it  off  the  triangular 
ligament.  Much  physical  force  was  required  in  the  enucleation,  which 
occupied  twenty-six  minutes  instead  of  the  usual  three  to  six  minutes. 
The  two  lobes.were  removed  separately.  Then-  was  considerable  bleeding, 
and  the  patient  seemed  much  collapsed,  with  feeble,  irregular  pulse;  by 
the  evening,  however,  the  pulse  was  strong  and  regular,  and  the  patient 
mo\  ed  about  in  bed  without  aid.  ( >n  February  2  he  passed  urine  copiously 
by  the  urethra,  and  on  February  17  the  abdominal  wound  had  closed. 
Tin  bladder  had  to  be  washed  out  daily  for  some  weeks,  as  the  urine 
contained  much  muco-pus.  On  March  18  he  went  home  in  good  health. 
He  could  retain  1 1  ounces  of  urine,  and  then  p,i^  it  as  well  as  ever  he 
did.     There  was  no  residual  urine. 

The  prostate  weighs  o|  ounces.     On  March  30  he  called  to  see  me. 

lb-  was  in  excellent  health  anil  spirits  :  able  to  pass  and  retain  his  mine. 

which  was  quite  clear,  as  well  as  he  ever  did. 

This  case   was  one  of  the   most  anxious  that    1    have   dealt    with,  pai 
ticularly  as  the  chronii    bronchitis  continued  lor  some  weeks  alter  the 
operation. 


96 


TOTAL  ENUCLEATION  OF  THE  PROSTATE 


Case  iSo. — Gentleman,  aged  sixty,  seen  in  consultation  with  Dr. 
J.,  J-  Macgregor,  of  London,  April  n,  1905.  Has  had  difficulty  in 
micturition  twelve  years.  Ten  years  ago  catheter  passed,  followed  by 
rigors.  Since  then  has  employed  catheter  regularly  ;  entirely  dependent 
thereon  for  eight  years.  Has  had  orchitis  twice,  cystitis  repeatedly,  and 
hematuria   occasionally.      Patient's    condition   very   distressing  ;    great 


^ 


pIG  3g. — Prostate,  weiching  $h  Ounces,  removed  from  Patient 
aged  Sixty  (Case  180). 

a,  1:,  Right  and  left  lobes  respectively.     The  transverse  constriction  is  the 
boundary  between  the  intravesical  and  extravesical  portions. 

loss  of  flesh  and  appetite  during  last  two  months  ;  extreme  dryness  of 
mouth  and  throat  ;  urine  turbid,  specific  gravity  1010,  contains  pus  and 
albumin ;  prostate  enormously  enlarged,  bilobed,  smooth,  soft,  rather 
dense,  but  movable  ;  easily  felt  bimanually. 

On    April    21,    Dr.    Silk   being  the   anaesthetist  and    Dr.    Macgregor 


TOTAL  ENUCLEATION  OF  THE  PROSTATE  97 

assisting,  I  removed  the  prostate  entire.  On  opening  the  bladder  the 
prostate  was  found  projecting  into  it  like  an  enormously  hypertrophied 
cervix  uteri,  the  left  lobe  being  more  prominent  than  the  right.  The 
inner  orifice  of  the  urethra  was  distorted  into  an  irregular  deep  slit 
between  the  lobes.  The  enucleation  was  easily  accomplished,  but  much 
difficulty  was  experienced  in  delivering  the  prostate  from  the  bladder. 
Eventually  it  was  grasped  by  one  lobe  and  withdrawn  like  an  open  oyster. 
There  was  considerable  bleeding,  and  the  time  occupied  was  eight 
minutes,  five  of  which  were  spent  in  delivering  the  prostate  from  the 
bladder.  Some  urine  was  passed  per  urethram  April  22,  but  the  supra- 
pubic wound  was  slow  in  closing.  It  was  thoroughly  healed  by  June  7 , 
after  which  all  urine  was  passed  naturally.  The  patient  left  for  home  on 
June  21  in  excellent  health,  passing  and  retaining  his  urine,  which  was 
quite  clear,  as  well  as  he  ever  did.  On  March  4,  1906,  he  wrote  :  '  I 
continue  to  be  in  good  health.  I  retain  urine,  and,  in  fact,  have  no 
difficulty  now.' 

The  prostate  (Fig.  38),  which  weighs  8h  ounces,  is  a  fine  specimen  of 
almost  symmetrical  enlargement  of  both  lobes.  The  enormous  size 
of  the  gland,  considering  the  age  of  the  patient,  is  very  remarkable.  It 
is  obvious  that  the  enlargement  had  considerably  advanced  before  the 
age  of  fifty. 

Let  us  now  contrast  the  characteristics  of  adenomatous 
enlargement  of  the  prostate  with  those  of  cancer  of  that 
organ  in  a  more  or  less  advanced  stage.  In  carcinomatous 
enlargement  we  find  on  rectal  examination  that  the  prostate 
is  mainly  hard — of  stony  hardness  in  most  instances — with 
possibly  soft,  boggy  patches  due  to  broken-down  tissue. 
The  outline  will,  as  a  rule,  be  irregular,  the  lobes  being  ill- 
defined,  and  the  median  furrow  partially  or  wholly  obliterated, 
In  such  cases  the  organ  will  be  nodular  or  ridged,  with 
intervening  deep,  irregular  furrows.  But  occasionally  the 
cancerous  prostate  will  be  smooth  and  globular,  like  an 
ivory  ball.  Most  important  of  all  for  diagnostic  purpo 
the  prostate  will  be  immovably  fixed  in  the  pelvis,  owing  to 
the  invasion  by  the  growth  of  the  surrounding  I 
Bimanual  examination  will  confirm  the  presence  ol  these 
characteristics;  but,  as  a  rule,  in  cancer  of  the  prostate  no 
a  prominence  of  the  organ  will  be  felt  inside  the  Madder, 

7 


98  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

the  growth  invading  the  surrounding  tissues  rather  than 
advancing  into  the  bladder.  We  will  have,  as  additional  aids 
to  diagnosis,  the  enlargement  of  the  glands  in  the  groins  in 
advanced  stages  of  the  malady ;  and  at  an  earlier  stage  small 
glands,  like  sago  grains,  may  be  felt  per  rectum  covering  the 
surface  of  the  tumour  beneath  the  mucous  membrane;  the 
clinical  history  of  the  case — viz.,  the  rather  sudden  inset  and 
rapid  advance  of  the  usual  prostatic  symptoms  ;  the  progres- 
sive loss  of  flesh  ;  the  feeling  of  lassitude,  debility,  and  undue 
fatigue ;  the  failure  of  appetite  ;  the  typical  cachexia  ;  and 
the  pains  in  the  loins,  sacrum,  and  lower  limbs,  the  result 
of  pressure  on  the  nerves,  so  characteristic  of  this  disease. 

It  is  impossible  to  enucleate  a  cancerous  prostate  in  this 
advanced  stage,  owing  to  the  extension  of  the  disease  to  the 
adjacent  tissues. 

In  the  earlier  stages  of  the  malady,  however,  whilst  the 
prostate  is  still  movable  and  the  surrounding  structures 
uninvolved,  the  gland  can,  and  should,  be  removed,  my 
experience  of  operation  under  such  conditions  being  most 
favourable.  It  is,  however,  impossible  to  give  a  definite 
diagnosis  of  malignancy  before  removal  of  the  gland  in  cases 
of  this  kind,  though  the  presence  of  dense  nodules  in  the 
prostate,  combined  with  the  rapid  progress  of  the  symptoms, 
will  arouse  suspicions  in  the  surgeon's  mind,  suspicions  which, 
I  need  scarcely  say,  should  be  communicated  to  the  patient's 
relatives  before  operation  is  undertaken. 

It  is,  however,  when  we  have  to  deal  with  adenomatous 
enlargements  of  smaller  dimensions — say,  less  than  ih  ounces 
in  weight — that  the  greatest  difficulties  present  themselves 
to  the  surgeon's  mind  as  to  the  possibility  of  their  enucleation 
entire  being  practicable  ;  for  I  may  say,  as  the  records  of  my 
published  cases  prove,  that  you  may  find  absolute  and  com- 
plete dependence  on  the  catheter,  with  a  prostate  weighing 
iA  ounces,  i  ounce,  or  even  less.     A  prostate  of  I  ounce  in 


TOTAL  ENUCLEATION  OE  THE  PROSTATE  99 

weight  will  scarcely  feel  enlarged  per  rectum,  and,  of  course, 
it  cannot  be  felt  bimanually.  The  only  way  in  which  we 
can  determine  the  possibility  of  enucleating  a  prostate  of  this 
size  is  by  the  aid  of  the  cystoscope.  If  on  cystoscopic  ex- 
amination we  find  that  there  is  a  well-defined  outgrowth  of 
one  lobe,  or  marked  prominence  of  both  lobes,  in  the  bladder, 
the  case  may  be  pronounced  to  be  one  permitting  of  enuclea- 
tion of  the  gland  entire,  no  matter  what  its  size  may  be  as 
felt  per  rectum.  I  will  give  details  of  some  examples  of  the 
kind  : 

Case  66. — Gentleman,  aged  fifty-six,  seen  in  consultation  with  Mr. 
John  Langton,  Harley  Street,  November  6,  1903.  Prostatic  symptoms 
for  two  years.  Cystoscopic  examination  attempted  a  year  previously,  but 
unsuccessfully,  owing  to  bleeding.  Intense  frequency  of  micturition  by 
day  and  night  so  that  sleep  was  impossible.  Condition  most  miserable. 
Much  averse  to  using  catheter  ;  in  constant  dread  of  retention.  Residual 
urine  only  2  ounces,  clear,  healthy.  Prostate  palpably  enlarged,  bilobed, 
soft,  movable.  We  made  a  cystoscopic  examination,  November  7,  with 
difficulty,  as  bleeding  again  set  in  ;  but  the  view  eventually  obtained 
revealed  a  thumb-like  outgrowth  of  the  right  lobe  of  the  prostate  in  the 
bladder.  I  at  first  counselled  postponement  of  operation  till  the  prost.ae 
should  have  grown  larger,  and  thus  become  more  easy  of  removal  ;  but 
Mr.  Langton,  who  knew  of  the  patient's  sufferings,  both  physical  and 
mental,  was  averse  to  delay,  and  eventually  it  was  decided  to  operate  at 
once. 

Operation,  November  9.  On  introducing  my  finger  into  the  bladder 
the  rij^ht  lobe  was  founl  projecting  inwards  for  \  inch.  The  prostate 
was  easily  and  rapidly  enucleated,  only  four  minutes  elapsing  from  com- 
mencing the  suprapubic  incision  till  the  inland  was  delivered  from  the 
bladder.  Rapid  and  uneventful  recovery,  urine  passing  naturally 
November  27,  and  the  wound  being  dry  December  1.  <  >n  December  3 
he  left  the  home  perfectly  well,  able  to  retain  \\\>  urine  for  five  or  six 
hours,  and  to  pass  it  naturally — '  not  so  well  sin<  e  he  was  a  boy.  as  the 
patient  expressed  it.  On  March  8,  1906,  he  wrote:  'I  have  had  no 
trouble  whatever  in  retaining  and  passing  urine  since  I  saw  you.1 

The  prostate  (Fig.    19  ,  winch  weighs  1  ounce,  is  a  pretty  specimen, 
and  shows  the  thumb-like  outgrowth  from  the  right  lobe  in  th< 
which  no  doubt  acted  a-  a  foreign  body,  giving  rise  to  irritation,  and 
acting  as  a  ball-valve  to  the  urethral  orifice. 

(\  IE  93. — Eminent  public  man.  aged  seventy-two,  seen  with  Dr.  1'.  F. 


ioo  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

Barton,  Wimbledon,  March  26,  1904.  Did  not  notice  any  urinary  troubles 
till  November,  1903,  when  he  had  great  frequency  of  micturition  with  foul 
urine,  and  great  distension  of  the  abdomen.  Catheter  passed,  and 
5^  pints  of  fetid  urine  drawn  off.  Entirely  dependent  on  catheter  since 
then  ;  urine  never  free  from  pus  ;  contains  albumin  and  casts.  Prostate 
not  felt  enlarged  per  rectum,  but  cystoscopic  examination  on  April  13 
revealed  an  outgrowth  therefrom  in  the  bladder.  Health  indifferent ;  had 
lost  17  pounds  in  weight  in  a  few  months. 

On  May  23,  Dr.  F.  Hewitt  anaesthetist,  I  removed  the  prostate,  weighing 
f  ounce,  entire  in  its  capsule  (  Fig.  41).     There  was  a  lower  lip,  h  inch 


Fig.  39. — Prostate,  weighing  i  Ounce,  removed  from  Patient 
aged  Fifty-six  (Case  66). 

A,  Left  lobe  ;  B,  right  lobe  ;  C,  finger-like  outgrowth  in  bladder  from  right 
lobe.     Catheter  indicates  course  of  urethra. 

long,  projecting  in  the  bladder,  and  acting  as  a  valve  to  the  inner  orifice, 
which  was  also  stenosed.  Urine  commenced  to  pass  naturally  April  14  ; 
wound  closed  May  22.  Went  home  May  28,  able  to  pass  and  retain 
urine  normally.  I  have  seen  the  patient  recently  ;  he  is  in  good  health, 
and  able  to  pass  and  retain  urine  as  well  as  ever. 

Case  182. — Gentleman,  aged  sixty,  sent  by  Dr.  J.  F.  Wolfe,  Heavitree, 
suffering  from  the  usual  prostatic  symptoms  for  five  years.  Catheter 
passed  daily  in  December,  1904,  but  abandoned  because  patient  could 
not  introduce  it  himself.  Cystitis  then  set  in,  accompanied  by  intense 
pain  and  frequency  of  micturition,  which  continued  till  I  saw  him  in 
April,  1905.  I  drew  off  28  ounces  residual  urine,  which  was  alkaline, 
and  contained  pus  and  mucus,  specific  gravity  1010.  Patient  had  lost 
much  flesh,  and  intense  thirst  was  a  prominent  symptom,  as  I  find  it 
is  frequently  when  chronic  over-distension  of  the  bladder  is  present. 

On  April  27,   1905,  I   enucleated  the  prostate  (Fig.  40)  entire  in  its 


TOTAL  ENUCLEATION  OF  THE  PROSTATE  101 

capsule,  the  weight  being  \  ounce.  The  prostate  was  very  dense,  but 
showed  no  signs  of  malignancy.  Urine  commenced  to  pass  naturally 
May  16,  and  the  wound  was  closed  May  19.  On  May  29  he  left  for  home, 
able  to  pass  and  retain  urine  naturally.  On  March  7,  1906,  he  writes  : 
'  My  general  health  is  very  ^ood.  I  am  able  to  pass  urine  fairly  freely, 
and  to  retain  it.' 

This  (Fig.  40)  is  one  of  the  smallest  prostates  I  have  removed.  It  is 
a  perfect  specimen,  complete  in  its  capsule. 

CASE  149. — On  September  24,  1904,  I  examined  a  patient,  aged  fifty- 
seven,  sent  by  Dr.  Latham,  of  Cambridge.  He  had  suffered  from  prostatic 
symptoms  for  seven  years.     Six   years  ago  he  had   retention  of  urine, 


Fig.   40.  —  Prostate   removed 

1    I'm  UN  1    \<;ed  Sixty 
(Case  182). 


Fig.   41.— Prostate,    weighing 
I    Ounce,    removed    from 

I'  \ni  \  1    v.i  11  Si-;\  i.N  rY-TWO 

(Case  93). 


which  was  drawn  off  by  the  catheter,  on  which  he  had  been  practically 
dependent  ever  sin<  e.  He  has  had  repeated  attacks  of  cystitis,  haemor- 
rhage, and  orchitis.  The  urine  contained  pus  and  albumin,  but  was  acid  ; 
specific  gravity  1015.  The  prostate  was  not  felt  much  enlarged  per 
return,  but  bilobed,  dense,  and  movable.  Bimanually  it  was  felt  pro- 
je<  ting  in  the  bladder.  <  In  the  patient's  return  home  lie  had  a  SC 
attack  of  cystitis  with  pyrexia,  which  prevented  his  coming  to  London  for 
operation  till  the  middle  of  November. 

<  >n  November  23  1  enucleated  the  prostate,  which  weighed  \\  oui 
entire,  easily  and   rapidily.  the   tune  occupied  being   five  minutes.     The 
piostate  presented  in  the  bladder  in  the  form  of  two  polypoid  outgrowths 
(Fig.  42,  b,  m.  that  from  the  right  lobe  being  the  size  of  a  plum,  and  that 


io2  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

from  the  left  the  size  of  a  cherry.  These  two  outgrowths  were  separated 
from  the  main  body  (c)  of  the  prostate  by  a  narrow  neck  produced  by 
constriction  of  the  sphincter  muscle,  a  portion  of  which  came  away  with 
the  prostate. 

The  recovery  was  uninterrupted  save  for  a  slight  swelling  of  one 
testicle.  Urine  passed  per  urethram  on  December  12,  and  the  wound 
was  dry  December  18.  On  December  29  he  went  home  in  good  health, 
able  to  pass  and  retain  his  urine  naturally.  On  February  24,  1906,  he 
writes  :  '  I  am  glad  to  say  there  is  no  difficulty  in  passing  and  retaining 
urine.     All  is  well.' 


Fig.  42.— Prostate,  weighing  i|  Ounces,  removed  from  Patient 
aged  Fifty-seven  (Case  149). 

A  and  B,  outgrowths  in  the  bladder  from  the  right  and  left  lobes  respec- 
tively, separated  from  the  main  body,  C,  by  a  narrow  neck. 

A  question  which  will  naturally  suggest  itself  is  this:  How 
is  it  that  prostates  of  these  sizes — which,  indeed,  are  not 
much  larger  than  that  set  down  in  the  text-books  as  the 
average  of  the  normal  prostate — can  give  rise  to  serious 
symptoms,  possibly  culminating  in  complete  retention  of 
urine  and  dependence  on  the  catheter  ?  The  explanation 
will  be  found  in  the  following  considerations. 


TOTAL  ENUCLEATION  OF  TILE  PROSTATE  103 

1.  The  late  Sir  Henry  Thompson  found  from  examination 
of  some  two  hundred  prostates  dissected  by  himself  and 
Dr.  Messer,  of  the  Royal  Naval  Hospital,  Greenwich,  and 
assumed  to  be  normal,  that  the  average  weight  was  about 
4!  drachms.  But  this  included  the  weight  of  the  sheath 
formed  from  the  recto-vesical  fascia,  whereas  the  latter  is 
left  behind  in  my  operation.  The  average  weight  of  the 
prostate  included  in  its  true  capsule,  exclusive  of  its  sheath, 
which  corresponds  to  what  is  removed  in  my  operation, 
would  be  considerably  less  than  this.  Now,  some  of  the 
prostates  referred  to  weighed  only  from  2  to  3  drachms, 
whilst  others  weighed  6  or  7  drachms.  The  portion  included 
in  the  true  capsule  of  a  prostate  weighing  with  its  sheath 
2  drachms  would  probably  not  weigh  more  than  ih  drachms. 
This,  if  hypertrophied  to  a  size  weighing  1  ounce,  would  be 
relatively  as  enlarged,  and  might  cause  just  as  severe  symp- 
toms, as  a  prostate  of  6  drachms  hypertrophied  to  3  or 
4  ounces,  and  might  be  as  easily  enucleable. 

2.  The  obstruction  caused  by  an  enlarged  prostate  does 
not  altogether  depend  on  its  size.  Of  more  importance, 
indeed,  in  this  connection  would  seem  to  be  the  tightness 
with  which  it  is  bound  down  by  the  encasing  sheath  of  recto- 
vesical fascia,  and  the  extent  and  conformation  of  the  out- 
growth in  the  bladder.  We  have  seen  that  in  Case  93, 
already  recorded,  a  prostate:  weighing  only  |  ounce,  situated 
mainly  extravesically,  and  tightly  compressed  by  its  sur- 
rounding sheath,  caused  complete  obstruction  to  the  flov*  of 
urine  for  six  months  previous  to  operation;  whereas  a 
prostate  enlarged  to  several  ounces  in  weight  may  give  rise 
to  little  trouble  for  many  years,  provided  thai  the  encasing 
sheath  be  loose,  elastic,  and  yielding,  or  that  in  the  course 
of  its  enlargement  the  organ  escapes  from  its  natural  extra- 
vesical  position,  and  b  mainly  intravesical,  bi 
thus  sel  free  fn  >m  the  encircling  grip  of  the  sheath.    Prostates 


io4  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

thus  displaced  into  the  bladder  may  afford  no  evidence  of 
enlargement  to  the  finger  placed  in  the  rectum,  but  will,  as 
a  rule,  be  detected  on  bimanual  examination,  or  by  the 
cystoscope.  The  following  are  instances  of  this  abnormal 
type  : 

Case  36. — Sir  J.  D ,  a  distinguished  member  of  the  medical  profes- 
sion, aged  seventy-one,  seen  at  Putney  in  consultation  with  Mr.  E.  White 
on  February  28,  1903.  Three  years  previously  had  painless  hematuria  for 
fourteen  days  without  apparent  cause.  Remained  quite  well  since  then 
till  January  21,  1903,  when  bleeding  again  set  in,  at  first  intermittent,  but 
latterly  continuous,  which  necessitated  his  remaining  in  bed  for  the  last 
three  weeks.  At  times  the  bleeding  was  very  profuse,  almost  pure  blood 
passing.  The  only  other  symptoms  were  great  frequency  of  micturition 
since  taking  to  bed,  not  before  ;  some  pain  at  the  neck  of  bladder  ;  and 
uneasiness  in  the  loins,  particularly  the  left.  The  catheter  had  latterly 
been  passed  twice  daily  and  the  bladder  washed  out.  Rapid  loss  of  flesh 
with  anaemia  during  last  few  weeks.  The  patient  had  been  seen  several 
times  by  Dr.  Allchin  and  Mr.  Makins,  by  whose  advice  I  was  called  in 
consultation. 

I  drew  off  1 5  ounces  residual  urine  containing  much  blood.  Sounded, 
but  no  stone  detected.  Prostate  somewhat  enlarged  per  rectum,  but  not 
at  all  prominent.  Bimanually  some  fulness  felt  in  the  bladder,  of  an 
indefinite  nature.  The  cause  of  the  haemorrhage  was  thus  very  obscure, 
and  grave  apprehensions  were  entertained  by  the  medical  gentlemen 
mentioned  and  myself  that  its  source  was  a  growth  either  of  the  bladder 
or  kidney. 

The  patient  was  conveyed  to  London  by  ambulance,  March  2,  and  kept 
in  bed  in  a  surgical  home,  under  the  observation  of  Mr.  Makins  and 
myself.  Rest  and  astringents  for  a  week  had  little  or  no  effect  in 
reducing  the  bleeding,  and  the  latter  rendered  diagnosis  by  the  cysto- 
scope impossible.  Examination  of  the  kidneys  by  the  X  rays  negative. 
Eventually  we  came  to  the  conclusion  that  the  haemorrhage  was  due 
either  to  a  growth  in  the  bladder  or  an  outgrowth  of  the  prostate,  so  we 
determined  to  open  the  bladder  suprapubically  for  diagnosis  and  such 
measures  as  might  be  found  advisable. 

On  March  9,  Mr.  White  giving  the  anaesthetic,  and  Mr.  Makins  kindly 
assisting  in  consultation,  cystoscopic  examination  revealed  an  irregular 
mass  in  the  bladder  ;  but  the  view  became  so  rapidly  obscured  from  the 
bleeding  that  no  definite  opinion  as  to  its  nature  could  be  formed. 
Suprapubic  cystotomy  was  forthwith  performed,  and  on  introducing  my 
finger  I  found,  happily,  that  the  growth  consisted  of  a  very  decided  out- 


TOTAL  ENUCLEATION  OF  THE  I3R0STATE  105 

growth  from  both  lobes  of  the  prostate,  united  below,  and  forming  a 
U-shaped  or  cart-horse-collar  projection  in  the  bladder.  The  lower  lip 
of  this  projected  1^  inches  beyond  the  neck  of  the  bladder.  The  prostate 
was  easily  and  rapidly  enucleated  entire  in  its  capsule,  the  urethra  being 
left  behind.  There  was  very  little  bleeding  or  shock.  The  patient  made 
a  most  satisfactory  recovery,  passing  some  urine  naturally  March  29,  and 
the  wound  being  quite  dry  April  1.  On  April  8  he  left  for  home  in  good 
health,  retaining  and  passing  urine  quite  naturally.  Since  the  opera- 
tion there  has  been  no  trace  of  haemorrhage. 

On  March  9,  1906,  three  years  after  the  operation,  the  patient  wrote: 
"  I  have  no  urinary  troubles  whatever,  am  never  disturbed  at  night,  and 
can  retain  and  pass  urine  naturally.  In  other  respects,  too,  I  am  quite 
well.' 

The  prostate,  which  weighs  2j  ounces,  is  an  excellent  specimen  of 
symmetrical  adenomatous  enlargement  of  the  organ.  The  case  is  a 
remarkable  one  from  many  points  of  view,  but  particularly  in  regard  to 
the  masked  character  of  the  prostatic  symptoms.  There  were  really  no 
external  signs  or  symptoms  to  indicate  prostatic  mischief,  as,  though  there 
was  a  large  quantity  of  residual  urine,  this  did  not  give  rise  to  the  usual 
symptoms  of  frequency  of  micturition  till  the  patient  took  to  bed.  It  has 
to  be  noted  that  there  was  profuse  haemorrhage  from  the  prostate  long 
before  a  catheter  was  employed,  due,  no  doubt,  to  a  varicose  condition  of 
its  veins. 

Case  105. — (icntleman,  aged  seventy-one,  sent  by  Dr.  A.  Emson, 
Dorchester,  consulted  me  June  6,  1904.  Symptoms  only  dated  from  ten 
months  previously,  when  he  had  retention,  relieved  by  catheter,  which 
was  used  twice  daily  for  a  fortnight.  After  this  urine  passed  naturally, 
and  patient  remained  fairly  well  till  six  weeks  previously,  when  retention 
a.L;ain  occurred.  Catheter  passed  occasionally  since  then  ;  haemorrhage 
and  much  pain  from  catheter  ;  micturition  every  two  hours  ;  residual  urine 
12  ounces;  contained  much  pus  and  blood;  general  health  very  bad; 
pulse  irregular  and  intermittent.  Prostate  scarcely  felt  enlarged  per 
rectum,  but  an  enormous  mass  palpable  bimanually,  and  cystoscopic 
examination  revealed  an  enormous  outgrowth  in  the  bladder. 

On  Jun<  ted  by  Dr.  Emson,  Dr.  Guthrie,  Stirling,  being  also 

present,  I    emu  leated  the   prostate    weighing   [1  I  entire  in  its 

<  .tpsule.  On  opening  the  bladder  suprapubic  ally  its  cavity  was  found 
filled  by  an  enormously  enlarged  prostate,  with  an  irregular  gaping 
urethral  01 1  lie  e,  ov<  rhung  above  and  on  the  left  by  a  massive  overgrowth 
of  the  left  lobe  (Fig.  43,  v),  and  on  the  right  by  a  large  mass  proje 
from  the  right  lobe  (b),  behind  whi<  h  was  an  ovoid  polypoid  outgrowth  (c)- 
The  right  and  left  lobi  ;  were  separated  by  a  deep,  gaping  fissure.  Th< 
prostate,  which  was  almost  entirely  intravesical,  was  easily  enucleated 


io6 


TOTAL  ENUCLEATION  OF  THE  PROSTATE 


entire,  the  lobes  opening  out  posteriorly,  but  remaining  united  in  front 
by  a  broad  band  (d).  There  was  considerable  bleeding  which,  however, 
soon  ceased  ;  operation  borne  well.  There  was  some  secondary  haemor- 
morhage  on  June  23,  and  again  on  June  26,  but  the  patient  steadily 
improved  ;  began  to  pass  urine  naturally  July  3,  and  in  volume  July  10  ; 
wound  closed  July  12  ;  sitting  up  daily  for  a  week  previously  ;  drove  out 


Fig.  43. — Prostate,  weighing  \o\  Ounces,  removed  from  Patient 
aged  Seventy-one  (Case  105).    Actual  Size. 

a,   Left  lobe  ;    B,  right  lobe  ;    c,  polypoid  outgrowth  from   right   lobe  ; 
D,  thin  band  of  sheath  removed  with  prostate. 

daily  after  July  12  :  went  home  July  21,  in  fairly  good  health,  untroubled 
by  any  urinary  symptom.  On  March  7,  1906,  he  writes  :  '  I  am  quite 
myself  again,  and  can  get  about  easily ;  free  from  pain,  and  retain  and 
pass  urine  as  well  as  ever.' 


TOTAL  ENUCLEATION  OF  THE  PROSTATE  107 

The  extremely  feeble  condition  of  this  patient  gave  cause  for  consider- 
able anxiety,  especially  as  the  kidneys  were  undoubtedly  much  affected  ; 
and  the  complete  recovery  is  remarkable,  taking  this  fact  and  the 
enormous  size  of  the  prostate  into  consideration. 

The  short  duration  of  the  symptoms,  and  the  patient's  not  being 
reduced  to  dependence  on  the  catheter,  are  also  very  singular  facts, 
considering  the  great  size  of  the  prostate.  These  circumstances  I 
attribute  to  the  enlarged  prostate  being  almost  entirely  intravesical, 
so  that  the  lobes  were  not  bound  down  by  the  recto-vesical  fascia,  and 
lateral  pressure  on  the  urethra  was  thus  obviated  to  a  large  extent. 

What  a  strange  contrast  this  case  presents  to  others  that  I  have 
recorded,  in  which  comparatively  slight  enlargements  of  the  gland, 
weighing  from  \  ounce  to  1  ounce,  caused  complete  retention  and 
dependence  on  the  catheter,  owing,  I  believe,  to  their  being  compressed 
by  some  peculiar  formation  of  the  recto-vesical  fascia,  which  does  not 
allow  of  free  expansion  of  the  prostate. 

Case  129. — Gentleman,  aged  seventy-eight,  seen  with  Dr.  W.  C. 
Luffman,  London,  September  15,  1904.  Prostatic  symptoms  for  ten 
years,  much  aggravated  during  last  two.  Completely  dependent  on 
catheter  for  seven  weeks.  Haemorrhage,  cystitis,  with  rigors,  and  tem- 
perature 104  F.  from  time  to  time.  Patient  very  stout  and  feeble, 
suffering  from  chronic  bronchitis.  Much  pus  and  mucus  in  urine,  specific 
gravity  1012.  Prostate  scarcely  felt  enlarged  per  rectum,  but  bimanual 
examination  revealed  its  size  as  that  of  a  large  orange  projecting  into  the 
bladder,  very  soft  and  movable. 

The  patient's  general  health  being  improved,  on  October  3  I  enucleated 
the  prostate  entire  in  its  capsule,  Major  J.  G.  Gordon,  I. M.S.,  and 
Dr.  J.  A.  Potts,  Ross,  Hereford,  being  present.  I  also  removed  an 
oxalate  of  lime  calculus  weighing  34  grains  from  the  bladder.  Time 
occupied,  six  minutes.  Troubled  much  with  bronchitis  for  a  few  days 
after  operation,  but  strength  gradually  improved.  Some  urine  passed 
naturally  October  15;  wound  dry  October  18.  Went  home  perfectly 
well  November  5;  able  to  pass  and  retain  urine  as  well  as  ever.  On 
Octobei  17,  1905,  he  called  to  see  me,  in  excellent  health.  Could  retain 
urine  four  or  five  hours  by  day,  and  six  or  seven  by  night,  and  pass  it 
with  perfect  ease;  in  fact,  better  than  he  ever  did  previously.  <  Ml 
Man  li  6,  1906,  the  patient  wrote  :  '  1  am  quite  well,  and  it  is  quit 

for  me  to  retain  or  pas-,  urine  as  ever  during  my  life,  or  as  anyone 
need  to;  and  the  urine  has  been  cleai  ev<  mj  leaving  the 

nursing  home.1 

The    prostate,    which  had    several    polypoid    out- 

growths in  the  bladder  from  the  right  lobe,  which  is  twice  the  size  of  the 
left. 


io8  TOTAL  ENUCLEATION  OF  THE  PROSTATE 

There  is  a  further  form  of  enlargement  of  the  prostate, 
which  is  partly  adenomatous  and  partly  inflammatory, 
occasionally  met  with,  in  which  the  patient  becomes  entirely 
dependent  on  the  catheter,  though  the  prostatic  enlarge- 
ment has  not  attained  to  any  considerable  dimensions. 
These  are  the  cases  in  which,  during  an  attack  of  cystitis, 
resulting  from  chill  or  other  cause,  the  inflammation  extends 
to  the  incipiently  enlarged  prostate,  resulting  in  retention  of 
urine.  A  catheter  is  passed  for  relief  of  this  retention,  and 
not  unfrequently  the  obstruction  regains  a  permanent  bar 
to  natural  evacuation  of  the  urine.  These  are  the  cases, 
I  presume,  that  are  commonly  spoken  of  as  instances  of 
'  fibroid '  prostate.  They  are  capable  of  being  removed 
entire,  if  well  defined,  or  projecting  into  the  bladder.  But  one 
cannot  assure  the  patient  beforehand  of  a  perfect  result,  as 
in  ordinary  adenomatous  enlargement  of  the  prostate  of 
advanced  age,  for  in  some  of  these  cases  the  bladder  never 
regains  the  power  of  completely  emptying  its  contents 
naturally,  there  being  a  certain  quantity  of  residual  urine 
left  behind.     Fortunately,  such  cases  are  rare. 


LECTURE  VI 

I.— TOTAL  ENUCLEATION  OF  THE  PROSTATE  IN 
ADVANCED  OLD  AGE 

One  of  the  most  remarkable  features  of  the  operation  of 
total  enucleation  of  the  prostate  is  the  success  that  has 
attended  its  employment  in  advanced  old  age.  Amongst 
some  300  patients  on  whom  I  have  performed  the  operation 
there  were  19  octogenarians,  varying  in  age  from  eighty  to 
eighty-seven  years,  and  3  bordering  on  this  period  of  life, 
aged  seventy-nine  years,  in  all  of  whom,  except  two,  the 
results  have  been  completely  satisfactory.  In  one  of  the 
fatal  cases  there  was  malignant  disease  of  the  bladder,  though 
the  prostate  was  adenomatous  apparently  ;  in  the  other  the 
case  was  complicated  by  vesical  stone  of  twelve  years  dura- 
tion and  disease  of  the  kidneys.  It  would  thus  appear  that 
age  has  little  influence  on  the  result  of  the  operation  provided 
that  the  vital  organs,  and  particularly  the  kidneys,  are 
unaffected  or  fairly  sound.  Nevertheless,  patients  of  this 
advanced  age  cause  much  anxiety  ;  and  the  operation  should 
not  be  undertaken  in  such  cases  unless  the  most  careful  and 
lender  nursing  is  available,  as  well  as  the  constant  personal 
supervision  of  the  surgeon.  I  will  give  details  of  several  of 
tlir-.  1 3  they  .n'«-  most  interesting. 

( '  \  >E  46.  A  well-known  publii  man.  aged  eight)  one,  seen  in  1  consulta- 
tion with  Dr.  II.  I..  Macevoy,  Brondesbury,  May  3,  1903.  Prostatic 
symptoms  for  ten  years,  gradually  increasing  in  severity.     Retention  of 


no     ENUCLEATION  OF  THE  PROSTATE  IN  OLD  AGE 

urine  four  years  previously,  relieved  by  catheter,  which  has  been  employed 
ever  since.  Great  frequency  of  micturition,  intense  pain  at  times,  and 
hematuria.  Seen  from  time  to  time  by  various  London  surgeons. 
Double  vasectomy  in  J900,  but  with  no  relief.  Condition  extremely 
miserable  during  last  six  months.  I  drew  off  8  ounces  residual  urine 
containing  much  pus  and  blood  ;  difficulty  in  introducing  the  catheter. 
Prostate  enormously  enlarged  per  rectum,  soft,  tense,  and  movable. 
Cystoscopy  on  May  4  revealed  an  outgrowth  of  the  left  lobe  of  the 
prostate  in  the  bladder,  the  size  of  a  plum.  Patient  in  very  feeble  health 
and  confined  to  bed. 

On  May  13,  Mr.  C.  Braine  being  the  anaesthetist,  Mr.  Thomson 
Walker  and  Dr.  Macevoy  assisting,  and  Colonel  W.  H.  Hender- 
son, I. M.S.,  being  present,  I  removed  the  prostate  entire  in  its  capsule, 
the  urethra  being  left  behind.  Some  trouble  was  experienced  in  the 
enucleation,  owing  to  stoutness  of  the  patient,  the  finger  with  difficulty 
reaching  the  aspect  of  the  gland  towards  the  triangular  ligament.  Time 
occupied  from  commencing  the  suprapubic  wound  till  the  prostate  was 
delivered  from  the  bladder,  thirteen  minutes.  There  was  very  little 
bleeding  and  no  shock. 

Uneventful  recovery,  the  temperature  remaining  normal  throughout. 
Some  urine  passed  naturally  June  2,  and  wholly  in  this  way  June  5. 
Patient  went  home  June  8,  twenty-six  days  after  operation,  retaining  and 
passing  his  urine  naturally,  and  he  is  now  in  excellent  health,  untroubled 
by  any  urinary  symptoms.  On  May  29,  1906,  three  years  after  operation, 
he  writes  :  '  I  am  pleased  to  tell  you  I  have  no  trouble  whatever  with 
passing  my  water,  thanks  to  your  treatment,  and  I  feel  very  well 
otherwise.' 

The  prostate  (Fig.  44),  which  weighs  5j  ounces,  is  an  excellent 
specimen  of  almost  symmetrical  adenomatous  enlargement  of  that 
organ. 

Case  67. — Gentleman,  aged  eighty-one  years,  was  seen  with  Mr.  C.  T. 
Knox  Shaw  on  October  29,  1903.  Prostatic  symptoms  had  been  present 
for  thirty  years  and  gradually  increasing.  The  catheter  had  been  passed 
in  June  1901,  showing  13  ounces  of  residual  urine.  Cystitis  supervened 
in  August,  with  much  pus  in  the  urine  and  rigors.  The  catheter  was 
passed  five  or  six  times  daily  in  November,  1902.  The  sound  was  passed 
under  an  anaesthetic  in  July,  1903,  by  another  surgeon,  but  no  stone  was 
found.  The  patient  had  been  entirely  dependent  on  the  catheter  since 
then,  with  much  pain  and  occasional  bleeding.  His  general  health 
was  bad.  The  prostate  was  greatly  enlarged  per  rectum;  it  was  broad, 
soft,  nodular,  and  movable. 

On  November  19,  Mr.  Shaw  and  Colonel  C.  Little,  I. M.S.,  being 
present,  I  removed  the  prostate  entire  in  its  capsule  with  several  small 


ENUCLEATION  OF  THE  PROSTATE  IN  OLD  AGE      in 

calculi  from  the  bladder.  There  was  considerable  bleeding,  and  the 
patient  was  feeble  for  some  days  after  the  operation.  By  the  29th  the 
suprapubic  wound  had  closed  so  rapidly  that  it  was  necessary  to  reinsert 
a  small  tube  to  prevent  spasm  of  the  bladder.  This  was  removed  on 
December  6,  and  on  the  same  day  the  patient  beyan  to  pass  urine 
naturally.  The  wound  was  closed  on  the  nth.  On  the  16th  he  went  out 
for  a  walk.  He  is  now,  zh  years  after  operation,  in  good  health  and  able 
to  retain  and  to  pass  his  urine  naturally.     On  May  9,  1906,  he  writes  : 


Fig.  44.    Prostate,  weighing  5J  Ounces,  removed  from  Patieni 

AGED    ElGHTY-ON]     (CASI    4^'). 

,\,  Right  lobe  ;   B,  left  lobe.     Catheter  lies  in  position  occupied  by  urethra. 


I  have  had  no  apprei  iable  trouble  with  my  waterworks  since  the  opera- 
tion in  November,  1903.  I  have  never,  from  that  date,  had  occasion  to 
l>e  otherwise  than  grateful  to  you  for  the  comfort  thus  acquired,  and. 
happily,  Sim  e  maintained.' 

The  prostate   Fig- 45  nces,  and  is  irregularly  enlarged  and 

bossy,  the  left  lobe  having  been  more  prominent  in  the  bladdei  than  the 
right 


H2     TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE 

Case  70. — Captain    M ,  aged   eighty-seven  years,  was  seen  with 

Dr.  H.  E.  Bruce  Porter,  of  Windsor,  on  November  22,  1903.  Pros- 
tatic symptoms  had  been  present  for  eight  years.  The  catheter  had 
been  employed  for  six  years,  and  the  patient  had  been  entirely 
dependent  thereon  for  five  years  ;  it  was  passed  every  two  hours.  The 
urine  contained  much  blood  and  ropy  muco-pus  ;  it  was  alkaline  and 
fetid.  The  catheter  passed  in  13^  inches  before  the  urine  flowedf;  a 
stone  could  be  felt  grating  against  its  end.    The  prostate  was  enormously 


Fig.  45.— Prostate,  weighing  4I  Ounces,  removed  from  Patient 
aged  Eighty-one  (Case  67). 

A,  Left  lobe;  B,  right  lobe. 


enlarged  per  rectum ;  it  was  roundly  bilobed,  smooth,  soft,  and  movable. 
The  patient  was  emaciated,  bearing  the  impress  of  terrible  suffering. 
'Life  not  worth  living  under  present  condition,'  as  he  put  it;  morphine 
was  given  daily  to  mitigate  the  pain.  He  had  an  intermittent  and 
irregular  pulse  ;  the  arteries  stood  out  like  whipcords  all  over  his  body. 
Rigors  and  fever  occurred  periodically.  He  came  to  London  on  Novem- 
ber 27,  and  his  bladder  was  washed  out  twice  daily.     On  December  4, 


TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE    113 

Mr.  C.  Braine  being  the  anaesthetist  and  Dr.  Porter  assisting,  I  opened 
the  bladder  suprapubically,  and  found  two  phosphatic  stones,  which  were 
removed  ;  they  weighed  ih  drachms.  Both  ureters  were  dilated  to  such 
an  extent  that  the  index-finger  passed  readily  into  them.  The  prostate 
was  felt  to  be  of  the  size  and  shape  of  a  cricket-ball,  and  was  jammed 
beneath  the  pubic  arch,  half  of  it  lying  in  the  bladder  and  half  outside. 
It    was  enucleated   entire  in  its  capsule.     Much  force  was  required  to 


Fig.  46. — Prosta  i  k.  weighing  6£  Ounces,  removed  from  Patieni 

AG!  D    ElGH  l  V    -IA  EN    (<    VSE   70). 

\.  Left  lobe  ;  B,  righl  lobe.      Each  showing  an  outgrowth  in  the  bladder. 


irate  it  from  the  surrounding  sheath.  The  time  from  commencing 
the  suprapubic  cystotomy  till  tin-  prostate  was  delivered  from  the  bladder 
was  seven  minutes.  There  was  scarcely  any  bleeding  or  shock.  The 
drainage-tube  was  removed  on  December  7.  There  was  not  an  un- 
favourable symptom.  No  morphine  had  been  given  since  the  operation. 
f  Talk  of  the  pains  of  an  operation,' said  the  patient ;' the  last  foui  days 
have  been  holidays  from  pain  amongst  many  years.'    He  sal  up  daily 

8 


ii4     TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE 

after  December  16.  He  passed  urine  naturally  by  December  20.  The 
wound  was  dry  on  the  23rd,  and  the  patient  was  walking  about.  On 
January  2, 1904,  he  travelled  home  in  good  health  and  spirits,  passing  and 
retaining  his  urine  naturally.  He  stated  that  he  felt  twenty  years  younger 
than  his  age — a  truly  grand  old  soldier  who  was  present  in  the  Sutlej  and 
Burmese  Wars  of  1845  and  1852.  On  May  1 1,  1904,  his  wife  wrote  :  '  He  is 
now  enjoying  life  free  from  any  pain  and  discomfort.'  On  September  8, 
1905,   Dr.  Bruce  Porter  wrote  :   '  Our  poor  old  mutual  patient,  Captain 

M ,  died  of  old  age.     From  the  time  you  did  your  operation  on  him 

his  life  was  a  new  one.  He  at  once  passed  from  absolute  torture  to 
absolute  comfort.  He  was  in  mind  and  body  years  younger.  After 
nearly  two  years  of  comfortable  life,  subsequent  to  operation,  his  circula- 
tion failed.     His  vessels  were,  as  you  know,  like  pipe-stems.' 

The  prostate  (Fig.  46),  which  weighs  6]  ounces,  is  a  fine  specimen  of 
symmetrical  enlargement  with  a  small  outgrowth  in  the  form  of  a  lip 
below  the  orifice  of  the  urethra. 

This  is  one  of  the  two  oldest  patients  on  whom  I  have  performed  this 
operation,  and  I  submit  that  the  result  was  a  great  surgical  triumph 
considering  his  age,  the  large  size  of  the  prostate,  the  weak  state  of  the 
patient,  the  presence  of  chronic  cystitis  with  formation  of  phosphatic 
calculi,  the  dilated  condition  of  the  ureters  from  backward  pressure, 
indicating  a  probability  that  the  kidneys  were  much  diseased.  In  spite 
of  all  this,  there  was  complete  restoration  to  health  and  function  of  the 
bladder. 

Case  85. — Gentleman,  aged  eighty-two  years,  was  seen  with  Mr.  J.  L. 
Hewer,  of  Highbury  New  Park,  on  March  2,  1904.  Prostatic  symptoms 
had  been  present  for  twenty  years,  and  the  patient  had  been  entirely 
dependent  on  the  catheter  for  ten  years.  He  experienced  great  difficulty 
and  pain  in  introducing  the  catheter  latterly,  two  hours  being  frequently 
spent  in  manipulating  the  instrument  before  it  passed.  He  had  had 
frequent  attacks  of  cystitis,  haemorrhage,  and  orchitis,  and  had  undergone 
seven  operations  for  vesical  calculus.  He  had  inguinal  hernia  requiring 
a  truss.  The  prostate  was  much  enlarged,  soft,  tense,  and  movable  ;  it 
could  be  felt  bimanually.     The  urine  contained  pus  and  mucus. 

On  March  7  I  removed  the  prostate  entire  in  its  capsule,  Mr.  Hewer 
assisting.  The  time  occupied  was  six  minutes.  The  operation  was  well 
borne.  Recovery  supervened  without  any  unfavourable  symptom,  the 
temperature  remaining  normal  throughout.  Urine  passed  naturally  on 
the  23rd,  and  the  wound  was  dry  on  the  25th,  eighteen  days  after  operation. 
The  patient  is  now  in  excellent  health,  attending  to  his  business  daily. 
On  July  19,  1904,  he  wrote  to  me:  'The  result  of  your  operation  has 
been  entirely  satisfactory.  I  am  now  able  to  pass  and  retain  the  urine 
as  well  as  I  ever  did.'     And  on   March  26,  1906:  'Yesterday  I  entered 


TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE     115 

my  eighty-fifth    year,  and   am    glad   to   say  I   am  enjoying  the  best  of 
health.' 

The  prostate  (Fig.  47),  which  weighs  5}  ounces,  presented  a  large 
tongue-shaped  outgrowth  in  the  bladder  growing  from  the  right  lobe. 
The  rapidity  with  which  the  wound  closed  is  remarkable  in  a  patient 
aged  eighty-two  years. 


FlG.  47.      Pi  ■  ISTATE,  u  EIGHING  5  PATH  NT 

:  d  Eighty-two  (< 
\.  Left  lobe;  B,  right  lobe,  presenting  .1  tongue-shap  iwth,  C,  in 

the  lil. 11 


<  \s\    >,< .     Em  ii'  al    scientist,  a  een  with 

Mr.   II.   Huxl<  iruary  17,  1904.     Prostatic  symptoms  had  been 

nt  for  five  years.    The  patienl  wa  with  an  0 

distended  bladder.     1   passed  a  1  atheter  and  drew  ofl 
clear  urine.    The    prostate  was  much  enl  tided,  smooth,  and 

movable.   His  general  health  was  good.    He  urine  naturally 

for  a  few  days,  but  eventually  h<-  was  completely  dependent   <>n   tin- 

-2 


n6     TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE 

catheter.  He  was  seen  again  with  Mr.  Huxley  on  May  3,  when  he 
travelled  to  London  for  operation,  as  catheter  life  was  unbearable.  His 
health  was  bad,  and  he  was  very  feeble.  Rapid  loss  of  flesh  had  taken 
place  during  the  last  two  months. 

I  enucleated  the  prostate  on  May  6.    The  gland  was  scarcely  prominent 
in  the  bladder  ;  it  was  firmly  bound  down  by  its  sheath.     There  was 


Fig.  48.— Prostate,  weighing  4  Ounces,  removed  from  Patient 

aged  Eighty-two  (Case  124). 
A,  Left  lobe  ;  B,  right  lobe,  prolonged  into  bladder  in  polypoid  form,  C. 

hardly  any  bleeding.  The  prostate  weighed  2£  ounces.  Progress  was 
most  favourable  till  May  10,  when  a  severe  attack  of  gout  set  in,  followed 
by  severe  inflammation  of  the  parotid  glands,  which,  however,  did  not 
suppurate.  Though  the  wound  kept  clean  throughout  progress  was  slow, 
owing  to  the  weak  state  of  health.  Urine  was  passed  naturally  by  June  2, 
and  entirely  per  ureihram  by  the  nth.  The  patient  left  the  surgical 
home  on  the  16th,  and  on  the  next  day  the  suprapubic  wound  reopened. 
A  catheter  was  tied  in  till  the  wound  closed  again.    I  met  this  gentleman 


TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE  117 

on  December  14,  1905,  nineteen  months  after  operation,  and  he  was  in 
excellent  health.     He  can  pass  and  retain  his  urine  normally. 

Case  124. — Gentleman,  aged  eighty-two,  seen  with  Dr.  Randell, 
Leckenham,  August,  10,  1904.  Catheter  employed  for  prostatic  obstruc- 
tion eight  years,  latterly  four  times  daily,  a  little  urine  being  passed 
naturally  every  two  hours  with  much  straining.  Haemorrhage,  cystitis, 
and  orchitis  from  time  to  time.  Catheter  introduced  with  difficulty. 
Prostate  greatly  enlarged  per  rectum,  bilobed,  soft,  smooth,  movable  ; 
felt  bimanually,  the  size  of  a  large  orange.  Health  feeble.  Inguinal 
hernia  requiring  a  truss. 

On  September  15,  Mr.  C.  Braine  being  the  anaesthetist,  Dr.  Randell 
assisting,  Drs.  de  Havilland  Hall  (London)  and  Runny  (Colchester! 
being  present,  I  enucleated  the  prostate  entire  in  its  capsule  easily  and 
rapidly  in  four  minutes.  Very  little  bleeding  ;  no  shock.  The  recovery 
was  uninterrupted,  urine  passing  naturally  October  12,  and  the  wound 
being  dry  next  day,  after  which  it  did  not  reopen.  Seen  by  Dr.  de  Havil- 
land Hall  September  23,  in  excellent  health,  able  to  pass  and  retain  urine 
as  well  as  he  ever  did.  Left  for  home  on  September  24.  On  January  26, 
1905,  he  wrote  :  '  I  am  quite  well,  and  as  active  as  ever ;'  and  on  Septem- 
ber 15,  1905:  'It  is  a  year  to-day  since  I  was  in  your  hands  for  the 
operation,  which  in  my  case,  as  in  many  others,  has  proved  a  very  real 
blessing.  I  can  look  forward  without  anxiety  to  what  remains  of  life. 
I  have  never  touched  a  catheter  since  the  operation.' 

The  prostate  (Fig.  481,  which  weighs  4  ounces,  presented  an  out- 
growth in  the  bladder  the  size  of  a  large  plum,  growing  from  the  right 
lobe. 

CASE    155. — Colonel    S ,  aged    eight) -three,  seen    with    Dr.    J.    C. 

I'errier,  S.  Norwood,  December  X,  1004.  Nad  prostatic  symptoms  six 
;  mm  h  aggravated  the  last  two  years.  Retention  of  urine  fifteen 
days  previously  :  entirely  dependent  on  the  catheter  for  ten  days.  Much 
pain  and  difficulty  in  introducing  1  atheter  ;  in  great  distress  from  1  ystitis ; 
attempting  to  pass  urine  every  lew  minutes.  Prostate  enlarged,  bilobed, 
tense,  movable  i  hit  bimanually.  Patient  stout,  general  health  fair,  pus 
and  albumin  in  urine. 

<  >n  December  10  patient  was  conveyed  to  London  in  an  ambulance, 
washing  out  the  bladder  daily  ami  preparing  him  for  operation,  on 
December  20,  Dr.  Ferrier  assisting  and  Mr.  C.  Braine  being  the  anaes- 
thetist, I  opened  the  bladder  suprapubically, removed  a  small  male  stone 
weighing  \g  grains,  and  then  enncleated  the  prostate  entire  (weight, 
2|   on:-     .  cupied,   ti\e  minutes.     Very  little   bleeding  ;   no 

shock.     No  unfavourable  symptoms  supervened.     Urine  commenced  to 
pass  naturally  Janu  ;;  wound  closed  January  12.    Onjanuai 

he  was  walking  about  his  room,  and  on  January  25,  when  he  left  lor  home. 


n8     TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE 

he  was  in  good  health,  passing  and  retaining  his  urine  as  well  as  ever  he 
did.  On  January  28  Dr.  Ferrier  wrote :  'I  am  exceedingly  pleased  to 
see  how  well  a  man  of  his  age  has  done  after  your  operation.'  On 
May  9,  1906,  the  patient  wrote  that,  though  his  general  health  was  feeble, 
there  has  been  no  return  of  the  urinary  symptoms  since  his  operation. 

Case  160. — Gentleman,  aged  eighty,  sent  by  Dr.  A.  M.  Mitchell, 
Guildford,  January  11,  1905.  Prostatic  symptoms  four  years.  Retention 
one  and  three  quarter  years  ago,  relieved  by  catheter,  which  has  been 
regularly  employed  since  then  ;  entirely  dependent  thereon  for  one  year. 
Cystitis,  haemorrhages,  intense  pain  in  penis  during  and  after  using 
catheter.  '  Urine  alkaline  ;  much  pus  and  mucus.  Has  been  in  bed  seven 
weeks,  and  was  so  feeble  that  he  had  to  be  conveyed  from  Guildford  to 
London  in  an  ambulance.  Heart  very  weak  ;  pulse  intermittent  and 
irregular.  Prostate  bilaterally  enlarged,  soft,  tense,  movable  ;  much 
pain  and  tenderness  during  examination,  due  probably  to  presence  of 
vesical  calculi.  Condition  of  patient  very  distressing  :  catheter  introduced 
with  much  pain  and  difficulty. 

On  January  16,  Dr.  Mitchell  assisting,  I  opened  the  bladder  supra- 
pubically  and  found  four  phosphatic  calculi,  weighing  185  grains,  which 
were  removed.  The  prostate  projected  into  the  bladder  in  the  shape  of 
an  enormously  hypertrophied  cervix  uteri  with  wide,  irregular  OS.  The 
prostate  was  enucleated  entire  without  difficulty,  and  weighed  2\  ounces. 
Time  eight  minutes,  four  of  which  were  expended  in  removing  the  calculi. 
Operation  well  borne  ;  no  shock. 

Progress  was  very  satisfactory,  the  patient  regaining  strength  rapidly. 
Some  urine  was  passed  naturally  January  24,  and  entirely  in  this  way 
after  February  6.  On  February  28  he  went  home  in  good  health,  passing 
and  retaining  his  urine,  which  was  quite  clear,  normally.  On  May  9, 
1906,  he  wrote:  'I  can  pass  urine  as  well  as  1  ever  could,  and  also 
retain  it  as  well,  with  some  very  rare  and  trifling  exceptions.' 

Case  174. — Eminent  scientist,  aged  eighty-two,  seen  in  consultation 
with  Mr.  G.  H.  Makins  and  Dr.  E.  A.  Roberts,  London,  March  25,  1905. 
He  had  suffered  for  fifteen  years  from  prostatic  symptoms,  the  most 
pronounced  of  which  was  gradually  increasing  frequency  of  micturition. 
A  catheter  had  been  passed  on  March  23  and  \\  pints  of  urine  drawn  off. 
Next  day  the  temperature  rose  to  10 1  F..  and  there  was  much  difficulty 
in  passing  the  catheter.  I  introduced  a  coudee  No.  8  with  some  difficulty, 
and  drew  off  15  ounces  of  thick  urine  containing  pus  and  mucus  ;  specific 
gravity  low.  The  prostate  per  rectum  was  much  enlarged,  broadly 
bilobed,  smooth,  soft,  movable  ;  felt  bimanually.  Patient  thin  but  wiry  ; 
high-tension  pulse.  Bowels  moved  when  he  strained  to  pass  urine. 
Obtained  scarcely  any  sleep  from  constant  desire  to  pass  water.  The 
case  was  regarded  as  one  very  suitable  for  removal  of  the  prostate  ;  but, 


TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE  119 

as  the  patient  was  suffering  from  acute  septic  absorption  from  the 
bladder,  we  considered  that  it  would  be  advisable  to  postpone  operation, 
if  possible,  till  this  condition  should  have  passed  off.  But  the  difficulty 
and  pain  attending  the  introduction  of  the  catheter  decided  us  on  fixing 
the  operation  for  March  c8.  On  March  26,  however,  the  temperature 
rose  to  J02  I-'.,  and  this  was  accompanied  by  nausea,  vomiting,  loss  of 
appetite,  drowsiness,  and  scanty  secretion  of  urine  ;  there  was,  in  short, 
partial  suppression  of  urine.  Under  these  circumstances  we  decided  to 
postpone  operation  for  the  time,  lest  the  shock  attending  it  might  cause 
complete  suppression  of  urine.  The  patient  was  extremely  disappointed 
at  the  postponement,  became  much  depressed,  and  his  strength  began 
rapidly  to  fail.  We  consequently  decided  that  the  proper  course  was 
to  risk  operation,  the  extreme  gravity  of  the  situation  being  fully  placed 
before  his  relatives. 

On  March  29,  in  consultation  with  Mr.  Makins  and  Dr.  Roberts, 
Dr.  Hewitt  being  the  anaesthetist,  I  removed  the  prostate,  both  lobes  of 
whii  h  were  very  prominent  in  the  bladder.  The  enucleation  was  easily 
accomplished,  the  time  occupied  from  commencing  the  suprapubic 
incision  till  the  prostate  was  delivered  Irom  the  bladder  being  six  minute-. 
There  was  scarcely  any  bleeding  and  no  apparent  shock.  But  there- 
was  much  nausea  and  vomiting  I  days,  and  on  March  31  the 
patient  brought  up  some  altered  blood  fiom  the  stomach;  next  day  there 
was  blood  and  mucus  in  the  stool  aft<  r-oil.  At  this 
period  we  had  the  advii  e  of  Sir  Thomas  Barlow  in  consultation.  These 
symptoms  were  regarded  as  unemic  in  origin.  After  the  bowels  were 
opened  there  was  a  profuse  discharge  of  urine  in  the  dressings,  so  that 
the  functions  of  the  kidneys  were  re-established.  From  this  period 
onwards  the  patient  made  sure,  though  slow,  progress  towards  recovery. 
Though  the  wound  kept  perfectly  clean  throughout,  the  temperature  did 
not  sink  to  normal  for  a  fortnight,  till,  in  fact,  the  se] 
absorbed  before  operation  had  been  eliminated  from  the  system. 

1  in  April  2  •.  on  inserting  the  nozzle  of  the  irrigator  in  tin-  suprapubic 
wound  and  filling  the  bladder,  the  lotion  was  passed  per  urethram  in  a 
continuous  stream.  <  m  Apt  il  26,  8  oun<  es  of  mine  were  passed  naturally. 
The  wound  was  dry  on  May  1  and  2,  and  all  urine  was  .  iturally  : 

but  it  reopened  on  May  3.  On  May  7  a  rubber  cathetei  was  tied  in,  and 
kept  there  till  May  14.  all  urine  being  passed  by  this  m- 

The  cathetei  was  removed  on  May  14th,  when  the  suprapubic  wound 
thoroughly   healed,   and    all   the   mine   subsequently   was   pas 
naturally.     The   patient  is  now — more  than  a  year  aftei  operation     in 
llenl  health,  able  to  pass  and  retain  his  urine  as  well  as  ever  he  did, 
and  leading  an  extremely  a<  live  life. 

The   prostate   (Fig.  49),  which   weighs  .',    ounces,  1-   symmetrically 


i-o     TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE 

enlarged,  each  of  the  lateral  lobes  presenting  a  pedunculated  outgrowth 
in  the  bladder  the  size  of  a  cherry. 

Case  187. — On  August  3, 1904,  I  was  summoned  to  Colchester  to  see,  in 
consultation  with  Dr.  E.  G.  Renny,  a  gentleman,  aged  eighty-six,  who  had 
been  suffering  from  prostatic  symptoms  for  five  years.  The  catheter  had 
been  used  off  and  on  for  six  months.  I  drew  off  16  ounces  residual 
urine,  turbid   but   acid.     The  prostate  was  much  enlarged  per  rectum, 


Fig.  49.— Prostate  weighing  2']  Ounxf.s,  removed  from  Patient 

AGED    ElGHTY-lWO    (CASE    174). 

A,  Right  lobe  ;  B,  left  lobe  :  c,  c',  pedunculated  outgrowths  in  bladder. 

bilobed,  smooth,  movable,  and  bimanually  was  felt  the  size  and  shape  of 
a  medium-sized  pear,  with  the  apex  in  the  bladder.  Patient's  general 
health  was  good,  and  the  case  was  regarded  as  a  very  suitable  one  for 
operation  ;  but  as  he  was  not  inclined  for  this,  I  advised  the  catheter  being 
employed  three  or  four  times  daily.  I  was  again  consulted  on  May  15, 
1905.  All  the  urine  had  been  passed  by  catheter  since  August,  1904. 
Patient  was  now  in  great  distress,  having  to  pass  the  catheter  every  half 


TOTAL  ENUCLEATION  OE  PROSTATE  IN  OLD  AGE     121 

to  one  hour  night  and  clay,  with  resulting  loss  of  sleep.  He  had  lost 
ground  decidedly  during  the  last  six  months  ;  his  general  health  was 
broken  ;  heart  irregular  and  intermittent;  both  the  lower  limbs  (edema- 
tous. Had  recently  suffered  from  phlebitis  of  left  thigh.  Urine  acid, 
specific  gravity  1012,  contained  pus  and  albumin.  The  case  was,  there- 
fore, a  very  grave  one  :  but,  as  the  patient  had  come  to  the  end  of  his 
tether  as  far  as  the  catheter  went,  I  determined  to  operate. 

Consequently,  on  .May  22.  Mr.  C.  Braine  being  the  anaesthetist, 
Dr.  Kenny  assisting,  and  Colonel  J.  Moorhead,  I. M.S.,  being  present, 
I  enucleated  the  prostate  entire,  easily  and  rapidly,  the  time  being  five 
minutes.  On  commencing  the  suprapubic  incision,  the  pulse  and  breath- 
ing ceased,  and  artificial  respiration  had  to  be  adopted  ;  but  I  proceeded 
with  the  operation,  and  the  enucleation  of  the  prostate  seemed  to 
stimulate  breathing.  Then-  was  scarcely  any  bleeding,  and  after  the 
operation  the  pulse  was  stronger  and  more  regular  than  before.  The 
prostate  was  pear-shaped,  symmetrically  enlarged,  one  half  of  it  lying  in 
the  bladder,  and  weighed  3^  ounces.  No  unfavourable  symptom  super- 
vened till  May  30,  when  the  temperature  rose  to  102  I-\.  due  to  an  attack 
of  bronchitis,  which,  however,  gradually  subsided  in  a  fortnight.  The 
wound  was  perfectly  clean  and  healthy  throughout,  but  the  fistula  was 
very  slow  in  closing,  owing  to  the  feeble  health  of  the  patient.  Began  to 
pass  urine  per  urethram  June  30  ;  wound  closed  July  9,  and  the  whole  of 
the  urine  passed  naturally.  On  May  9.  1906,  about  a  year  after  operation, 
he  wrote  :  '  1  am  also  glad  to  say  that  ihe  urinary  organs  are  now  quite 
sound,  and  I  can  pass  and  retain  water  as  well  as  ever.1 

Case  194.— Gentleman,  aged  eighty-seven,  seen  in  consultation  with 
Dr.  H.  Roger  Smith,  Hampstead,  May  31,  [905.  Bladder  symptoms  for 
seven  years.  Stone  1  rushed  by  another  surgeon  five  years  ago.  Since 
then  has  had  to  use  the  catheter,  at  first  once  daily,  gradually  increasing 
in  frequency  till  he  now  passes  it  six  times  daily.  Passes  a  little  urine 
naturally,  accompanied  by  much  pain  and  spasm.  Urine  alkaline,  fetid, 
contains  much  pus  and  mucus,  Has  passed  blood  frequently.  Patient's 
condition  most  distressing  :  feels,  as  he  says,  that  he  can  no  longer  go 
on  with  the  catheter.  Prostate  much  enlarged  per  rectum,  bilobed,  soft, 
smooth,  movable,  felt  bimanual!)-.  General  health  fair,  but  troubled 
with  brom  liial  <atai  ill.  Suffering  from  double  inguinal  hernia  and  double 
hydro 

On  June  6,  Mr.  C.  Braine  being  anaesthetist,  Mr.  Thomson  Walker 

and  Dr.  Roger  Smith  assisting,  1  emu  hated  the  prostate  entire  in  its 

capsule  easily  and  rapidly.     There  was  a  -mall   phosphatii    Stone,  we 

ing  23  grains,  found  in  the  bladder.    Time  occupied,  including  removal 

ulus,  ti\e  minuter.     The  prostate  was  the  size  of  a  large  I  angerine 

je,  almost  symmetrical,  and  weighed  :  ounces.     Then-  was  scarcely 


122     TOTAL  ENUCLEATION  OF  PROSTATE  IN  OLD  AGE 

any  bleeding,  and  no  shock.  The  recovery  was  unaccompanied  by  any 
unfavourable  symptoms,  the  temperature  remaining  practically  normal 
throughout.  In  fact,  the  patient  scarcely  felt  the  operation  in  any  way. 
He  passed  urine  naturally  June  20,  and  the  wound  was  dry  July  I. 

After  July  3  he  sat  up  daily  and  walked  about  his  room.  The  ease 
with  which  the  operation  was  borne,  and  the  rapidity  of  convalescence 
are  extremely  remarkable  at  this  great  age.  On  May  10,  1906,  he  wrote  : 
'  My  waterworks  are  in  excellent  working  order,  and  have  been  so  ever 
since  I  was  under  your  care.  Every  time  I  pass  water  I  feel  grateful  for 
the  ease  and  comfort  I  now  enjoy  compared  with  the  misery  of  my  life 
when  I  put  myself  under  your  most  skilful  operation.' 

Case  268. — Gentleman,  aged  eighty-three,  seen  at  Reigate  in  consulta- 
tion with  Dr.  H.  S.  Stone,  February  1,  1906.  Prostatic  symptoms  for 
twenty  years,  much  aggravated  during  the  last  five.  Renal  colic  twelve 
years  previously.  Fifteen  days  ago  catheter  passed  by  another  medical 
man  followed  by  bleeding.  Retention  of  urine  a  week  ago.  Difficulty 
in  introducing  catheter,  so  an  anaesthetic  was  given  and  a  catheter  tied 
in,  urine  very  thick  and  offensive.  Prostate  greatly  enlarged  per  rectum, 
bilobed,  soft,  movable;  not  felt  bimanually,  owing  to  extreme  stoutness 
of  patient. 

As  patient  was  rapidly  losing  ground,  and  could  not  tolerate  the  intro- 
duction of  a  catheter  except  under  an  anaesthetic,  operation  was  decided 
on.  On  February  5,  assisted  by  Dr.  Stone,  I  opened  the  bladder  supra- 
pubically.  The  fat  of  the  abdomen  was  4  inches  deep  before  the  recti 
muscles  were  reached.  Two  large  oxalate  of  lime  calculi,  weighing 
\\  ounces,  were  found  lying  behind  the  prostate  and  removed.  The 
prostate  was  easily  enucleable  except  that,  owing  to  the  patient  being 
extremely  stout  and  short  in  the  trunk,  its  distal  aspects  were  with  diffi- 
culty reached  by  the  finger.  Time,  twelve  minntes,  half  of  which  was 
occupied  in  removing  the  calculi.  The  right  lobe  of  the  prostate,  which 
weighed  5  ounces,  was  three  times  the  bulk  of  the  left.  There  was  little 
bleeding,  and  the  operation  was  well  borne. 

During  the  first  two  days  the  urine  was  scanty  and  devoid  of  its  usual 
odour,  and  hiccough  was  very  distressing,  indicating  uraemia.  Then  the 
functions  of  the  kidneys  were  re-established,  and  satisfactory  progress  was 
made  for  about  a  week.  But  the  patient,  though  bright  and  cheerful  at 
times,  and  entirely  free  from  pain,  repeatedly  said  that  he  would  not 
recover — that  he  had  no  desire  to  do  so,  as  his  course  of  life  had  run. 
He  gradually  passed  into  a  comatose  state,  and  died  fifteen  days  after 
operation.  No  doubt  the  kidneys  were  much  affected  as  the  result  of 
the  putrid  urine  caused  by  the  prostate  and  long-standing  calculous 
disorder. 

Case   280. — Gentleman,  aged    eighty-four,  seen  in   consultation  with 


TOTAL  ENUCLEATION  OE  PROSTATE  IN  OLD  AGE    123 

Dr.  P.  L.  Read,  South  Kensington,  March  16,  1906.  Prostatic  symptoms 
dated  from  seventeen  years  ago,  when  he  was  advised  by  a  surgeon  to 
use  a  catheter.  He  dispensed  with  this  till  a  year  ago,  when  cystitis, 
accompanied  by  rigors  and  pyrexia,  set  in,  and  another  surgeon  was 
consulted.     Catheter  employed  four  or  five  times  daily  till  three  weeks 


Fig.  50. — Prostati   weighing  j\  Ounces,  removed  from  Patient 
.v. 1  i>  Eigh  rv-i  ..Ik  (Case  280). 
B,  \.  Thin   layer  of  sheath  attached;  i>,  placed   over  anterior  com- 
growths  iifl.itcr.il  lobes  in  bladder. 

previously,  when  he  hid  in  give  it  up  owing  t<>  the  pain  and  difficulty  in 
it>  introduction.     Condition  very  1  of  micturi- 

tion day  and  night;  bladder  much   distended.    General   health 
l    passed   .1  bicoudee  catheter  with  difficulty  and  drew  off  15  ou 


124     TOTAL  ENUCLEATION  OE  PROSTATE  IN  OLD  AGE 

residual  urine,  thick  with  pus  and  mucus.  Prostate  greatly  enlarged, 
bilobed,  dense,  movable  ;  felt  bimanually  the  size  of  a  large  orange. 

On  March  20,  Dr.  Read  assisting,  I  enucleated  the  prostate  (Fig.  50) 
entire,  with  a  thin  layer  of  the  sheath  adherent  thereto,  easily  and 
rapidly,  the  time  occupied  being  five  minutes.  The  patient  scarcely  felt 
any  inconvenience  from  the  operation,  and  read  the  newspapers  daily 
after  the  first  day.  Some  urine  passed  naturally  on  April  8,  and  the 
wound  was  closed  on  April  11.  He  was  sitting  up  out  of  bed  on  April  9, 
and  went  for  a  drive  on  April  15.  Within  four  weeks  fiom  the  date  of 
operation  he  resumed  business  in  the  City,  and  is  now  in  excellent  health, 
untroubled  by  any  urinary  symptoms. 

The  prostate  (Fig.  50)  weighs  ~]\  ounces.  A  thin  layer  of  the  sheath 
(b,  a)  came  away  with  the  prostate,  being  very  adherent  thereto.  The 
letter  D  is  placed  over  the  line  of  the  anterior  commissure,  marking  the 
separation  of  the  lateral  lobes,  which  were  continued  as  irregular  projec- 
tions (c,  C')  in  the  bladder,  covered  by  the  true  capsule  of  the  prostate. 


II.— ENUCLEATION  OF  THE  WHOLE  OR  REMAINING 
PORTIONS  OF  THE  PROSTATE  IN  CASES  PREVIOUSLY 
SUBJECTED  TO  OPERATION  BY  OTHER  METHODS. 

Numerous  instances  have  been  recorded  in  detail,  in  my 
published  lectures  and  papers,  of  patients  suffering  from 
enlarged  prostate  who  had  been  previously  subjected  to 
operation  by  other  methods  unsuccessfully,  but  who  were 
completely  cured  by  my  method  of  total  enucleation  of  the 
organ,  or  of  the  portions  left  behind  in  cases  of  partial 
prostatectomy.  A  collection  and  arrangement  of  these 
under  their  proper  headings  will  prove  both  interesting 
and  instructive. 

1.  Cases  previously  subjected  to  Castration. 

Case  43. — A  gentleman,  aged  seventy-one,  consulted  me  March  28, 
1903,  for  prostatic  troubles.  Catheter  employed  for  twenty  years  ;  not 
a  drop  of  urine  passed  naturally  for  last  eighteen  years.  Calculi  removed 
by  crushing  on  three  occasions  by  London  specialist  ;  double  castration 
by  another  London  surgeon  for  cure  of  prostatic  troubles  in  1897,  but 
without   any  amelioration  of   his  symptoms.      Slight  paralytic  stroke  in 


CASES  PREVIOUSLY  SUBJECTED  TO  CASTRATION     125 

January,  1903,  from  which  he  completely  recovered,  but  has  had  a  nurse 
ever  since.  Extremely  feeble  and  hysterical  ;  breaks  down  and  weeps 
without  apparent  cause.  Patient's  condition  most  pitiable.  Hematuria 
from  time  to  time.  Urine  contains  much  pus  and  blood,  and  is  most 
offensive;  bladder  can  retain  only  small  quantity;  hence  catheter  used 
half-hourly    day    and    night.       Enormous    enlargement    of   prostate   per 


-   Pri  ISTA1  l  .  W  1  IGHIN  iVED 

ikom  Patient  aged  Seventy-one    Casi    ; 

\.  Right  lobe  :  i'.,  left  lobe.     The  transvei  'lie 

boundary  between  the  intravesical  and  extravesical  portions. 


rectum,  M>ft,  smooth,  bilobed,  movable.   Cystoscopyon  Map  h  30 revealed 

an  enormous  outgrowth  <>t  prostate  in  the  bladder. 

<  )n  April  1,  Mi.  Wylie  assisting,  I  enui  leated  the  prostate  entire  in  its 

lie.     I  In  prostate  projected  into  tin-  bladder  in  the  form  of  a  cone, 

the  urethra]  orifice  bciny  shaped  like  the  cratei  of  .1  volcano.     '  onsider- 


126     CASES  PREVIOUSLY  SUBJECTED  TO  CASTRATION 

able  force  had  to  be  employed  to  separate  the  capsule  from  the  sheath. 
After  delivery  of  the  prostate  as  a  whole  into  the  bladder,  owing  to  its  large 
size,  the  lobes  had  to  be  separated  to  facilitate  its  removal,  though  it  was 
very  soft  and  spongy.  Only  eleven  minutes  elapsed  from  commencing  the 
operation  till  the  prostate  was  delivered  from  the  bladder.  There  was 
scarcely  any  bleeding  or  shock.  The  patient  made  an  uneventful 
recovery.  Urine  passed  naturally  April  26,  and  the  wound  was  dry 
May  5.  He  was  quite  overcome  with  joy  at  passing  urine  naturally  again 
after  eighteen  years  of  complete  catheter  life.  Went  home  May  II,  in 
excellent  health,  able  to  retain  and  pass  his  urine  as  well  as  ever  he  did. 
On  March  14,  1906,  nearly  two  years  after  operation,  he  writes  :  lI  am 
pleased  to  tell  you  that  I  pass  urine  quite  freely,  and  retain  it  all  right.' 

The  prostate  (Fig.  51),  which  weighs  Sj  ounces,  is  a  very  large  one. 
The  right  lobe  (a)  is  enormously  enlarged,  the  left  lobe  (b)  less  so.  The 
case  is.  indeed,  a  remarkable  one,  showing  what  wonderful  results  may 
be  accomplished  by  this  operation  even  when  the  patient  is  almost 
moribund. 

Case  116. — Gentleman,  aged  sixty-two,  came  from  Trinidad  to  consult 
me,  on  the  advice  of  Dr.  Eakin,  Port  of  Spain,  August  19,  1903.  Pros- 
tatic symptoms  eleven  years.  Double  castration  performed  by  a  London 
surgeon  in  1896  for  cure  of  his  disease,  but  with  no  benefit  whatever. 
Completely  dependent  on  the  catheter  six  years  ;  chronic  cystitis ; 
haemorrhage  twice.  Prostate  size  of  a  walnut,  hard,  movable  ;  scarcely 
felt  bimanually,  as  patient  was  very  stout.  I  advised  removal  of  the 
prostate  ;  but  the  operation  was  postponed  for  a  year,  owing  to  pressure 
of  business.  On  his  return,  in  July,  1904,  patient  was  in  much  the  same 
state;  catheter  used  five  or  six  times  daily;  urine  'fishy'  in  odour, 
contained  much  pus  and  mucus. 

With  the  assistance  of  Mr.  Thomson  Walker  I  enucleated  the  prostate, 
weighing  \\  ounces,  entire  in  its  capsule,  July  21,  easily  and  rapidly. 
Urine  began  to  pass  naturally  August  4,  but  the  suprapubic  wound  was 
slow  in  completely  closing.  I  saw  him  on  September  23,  previous  to  his 
departure  for  Trinidad.  He  was  in  excellent  health,  the  wound  firmly 
closed,  and  he  could  pass  and  retain  urine  as  well  as  he  ever  did. 

2.  Cases  previously  subjected  to  Vasectomy. 

Case  19. — An  eminent  physician,  aged  sixty-six,  with  prostatic  symp- 
toms for  ten  years  ;  the  whole  of  the  urine  passed  by  catheter  for  three 
years ;  also  suffering  from  diabetes.  On  entering  on  catheter  life 
suffered  from  glycosuric  urethritis,  which  resulted  in  stricture,  rendering 
catheterism  painful  and  difficult.  In  November,  1899,  I  dilated  the 
stricture  under  an  anaesthetic,  since  which  time  a  large  metal  sound  had 


CAS£S  PREVIOUSLY  SUBJECTED  TO  VASECTOMY      127 

been  passed  periodically  to  keep  the  canal  open.  Double  vasectomy  in 
February,  1900,  with  no  benefit  to  the  prostatic  symptoms,  though  it 
prevented  the  recurrence  of  orchitis  resulting  from  the  use  of  the  catheter. 
1  had  the  advantage  of  the  advice  of  several  distinguished  members  of 
our  profession  in  this  case,  including  Sir  Dyce  Duckworth,  Mr.  Reginald 
Harrison,  Drs.  Gilbart  Smith  and  R.  Hutchinson.  The  patient's  condi- 
tion was  most  distressing,  and  during  the  past  year  he  repeatedly  sug- 
gested removal  of  the  prostate,  but  I  postponed  compliance  with  his 
wish  till  the  symptoms  became  unbearable.  The  dangers  of  an  operation 
of  this  kind  in  the  diabetic  state  were  fully  laid  before  him  ;  but  at  the 
final  consultation  he  stated  that  death  would  be  preferable  to  his  suffer- 
ings from  catheter  life,  so  I  yielded  to  his  appeal  for  operation.  Cysto- 
scopy on  June  18;  'middle 'lobe  prominent  in  bladder.  Prostate  per 
rectum  globular,  tense,  smooth,  movable. 

On  July  17,  1902,  Mr.  C.  Braine,  anaesthetist,  and  Drs.  Gilbart  Smith 
and  Hugh  Playfair  being  present,  I  removed  the  prostate  suprapubically. 
It  was  found  impossible  to  separate  the  lobes  along  their  anterior  com- 
missure, so  the  gland  was  removed  as  a  whole  with  the  prostatic  urethra. 
There  was  very  little  shock,  though  there  was  considerable  oozing  of 
blood  for  twenty-four  hours.  Recovery  without  any  unfavourable  symp- 
tom, the  temperature  remaining  practically  normal,  some  urine  passing 
naturally  at  the  end  of  the  first  week,  and  the  suprapubic  wound  being 
completely  closed  on  August  7.  He  drove  out  daily  from  August  9,  and 
travelled  to  Scotland  August  14  — twenty-eight  days  after  operation.  He 
continued  in  excellent  health,  able  to  pass  and  retain  his  urine  quite 
naturally  till  April  1903,  when  he  sustained  a  stroke  of  paralysis  from 
which  he  eventually  died.  <  >n  August  18,  1903,  his  wife  wrote:  'What 
his  helplessness  would  have  meant,  only  for  that  operation,  you  and  I 
alone  know.  His  first  words  after  his  attack  in  Florence  were,  'Thank 
God  for  my  operation.' 

This  (Fig.  521  is  the  prostate,  weighing  3  ounces.    The  so-called  middle 

(a)  grows  mainly  from  the  l(  it  lobe  (<  I.      I  he  whole  is  encircled  by 

a  thin  fibrous  and  muscular  band     l»  ,  part  of  the  sheath   formed  by  the 

recto-vesical  fascia  removed  with  the  prostate.     The  lateral  lobes  (b,  c) 

are  seen  covered  by  their  true  capsule. 

I  may  say  that  this  was  one  of  the  mosl  anxious  rases  of  my  life,  owing 
to  the  coexisting  diab 

( '  \-i.  1 1.     I  olonel  M ,  aged  sixty  one,  1  onsulted  me  on  Janua 

1903,011  the  advice  of  l>r.  Guthrie  Caley,  Ealing.     Prostatic  symptoms 
leven  years.     Retention  of  mine  in    (892;  relieved  by  catheter  by 
1  )r.  Simpson  of  \\  eymouth.   <  latheter  employed  continuously  since  then  ; 
inim   1  ntirely  by  catheter  for  last  eight  years.     Frequent  att 

ot  cystitis  ;  passing  Mood  since  September,  1902.     Vasectomy  pertf 


128      CASES  PREVIOUSLY  SUBJECTED  TO   VASECTOMY 


in  1897  by  a  provincial  surgeon:  no  improvement  whatever  therefrom. 
Prostate  much  enlarged  per  rectum,  bilobed,  soft,  elastic,  movable. 
Cystoscopy  on  January  14  revealed  an  enormous  outgrowth  of  the  right 
lobe,  resembling  a  large  tomato,  in  the  bladder,  and  slight  outgrowth  of 
the  left  lobe.  Patient  went  home  and  contracted  influenza  some  days 
after,  which  left  him  very  feeble. 


D 


Fig.  52.— Prostate,  weighing  3  Ounces,  removed  from   Patient 
aged  Sixty-six  (Case  19). 

A,  'Middle'  lobe  growing  mainly  from  left  lobe,  C;  D,  fibro-muscular 
band  from  sheath  removed  with  prostate,  encircling  lateral  lobes, 
which  are  seen  at  C,  B,  covered  by  their  true  capsule. 

He  returned  to  London,  and  entered  a  surgical  home  on  January  28, 
but  was  so  feeble  that  I  deferred  operation.  On  February  1 1,  Sir  William 
Collins  and  Dr.  A.  Crombie  being  present,  I  removed  the  prostate  easily 


CASES  PREVIOUSLY  SUBJECTED  TO  VASECTOMY     129 

and  rapidly,  entire  in  its  capsule,  leaving  the  urethra  behind  uninjured. 
Some  urine  passed  naturally  February  25  ;  wound  closed  March  3. 
Temperature  normal  throughout.  Patient  left  for  home  in  good  health 
March  14,  retaining  and  passing  his  urine  as  well  as  he  ever  did. 
On  March  19,  1906,  more  than  three  years  after  operation,  he  wrote  :  '  I 
have  been   very  well  indeed,  and    have  had  no  symptoms  whatever  of 


Fig.  53.— Prosi  vte,  weighing  \\  Ounces,  removed  from  Pati 

v;i..D  S;\  ry-ONl  14). 

B,  Enormous  outgrowth  of  right  lobe  in  bladder:   \,  smaller  growth  >>\ 
left;  c,  c',  circular  groove  caused  by  constriction  of  recto-w 
t.i  }<  i  1  .it  neck  of  bladdi 

bladder  trouble  of  any  kind.     A  perfect  and  uninterrupted  flow  ol  watei 
when  necessary.   February  u,  the  anniversary  of  the  wonderful  operation) 
is  kept  as  .1  sort  of  second  birthday.' 
The  prostate  .  winch  weighs  j|  ounces,  is  a  remarkable  speci- 


130     CASES  PREVIOUSLY  SUBJECTED  TO  VASECTOMY 

men  of  unsymmetrical  growth.  Three-fourths  of  its  bulk  lay  in  the 
bladder,  the  right  lobe  being  enormously  enlarged  in  this  direction,  and 
the  left  only  slightly  so. 

Case  45.— A  member  of  the  medical  profession,  aged  sixty-one,  with 
prostatic  symptoms  for  four  years.  Retention  two  and  a  half  years  ago, 
relieved  by  catheter  by  Dr.  Beaver,  Sturminster  Newton.  Had  double 
vasectomy  performed  by  a  well-known  provincial  surgeon  ;  no  relief 
therefrom.  Practically  the  whole  of  the  urine  by  catheter  for  eighteen 
months  ;  several  attacks  of  cystitis.  Prostate  decidedly  enlarged  per 
rectum,  rounded,  soft,  tense,  smooth,  and  movable.  Cystoscopy  on 
March  4  revealed  well-marked  outgrowths  of  both  prostatic  lobes  in  the 
bladder,  particularly  of  the  left. 

On  April  6,  1903,  I  removed  the  prostate  entire  in  its  capsule,  the  lobes 
opening  out  along  their  superior  commissure,  leaving  the  urethra  unin- 
jured. The  patient  was  only  twenty-three  minutes  on  the  operating  table, 
and  only  seven  minutes  elapsed  from  commencing  the  suprapubic  wound 
till  the  prostate  was  delivered  from  the  bladder.  Scarcely  any  bleeding 
or  shock.  Several  ounces  of  urine  were  passed  naturally  during  the  first 
few  days  ;  then  all  the  urine  by  the  suprapubic  wound  for  several  days. 
The  latter  finally  closed  May  3.  During  the  first  ten  days  the  wound 
was  covered  by  much  phosphatic  grit,  which  required  removal  twice 
daily,  and  some  grit  was  also  passed  per  urethram  with  the  urine.  The 
patient  left  for  the  country  May  5,  in  excellent  health,  able  to  retain  and 
pass  his  urine  naturally.  I  understand  that  he  has  recently  read  a  paper 
on  his  own  case  at  a  branch  meeting  of  the  British  Medical  Association. 
On  March  14,  1906,  nearly  three  years  after  operation,  he  wrote  :  '  I 
can  truly  say  I  am  quite  well,  pass  an  abundant  stream  and  retain  my 
urine  as  well  as  ever.  I  can  go  to  bed  at  eleven  o'clock  and  sleep  till 
seven.' 

lire  prostate  is  an  excellent  specimen  of  non-symmetrical  enlarge- 
ment, the  left  lobe  being  much  more  bulky  than  the  right.  It  weighed 
1 1  ounces. 

Case  78. — Medical  man,  aged  fifty-nine,  seen  with  Dr.  G.  S.  Hart, 
Mesham,  January  19,  1904.  Prostatic  symptoms  ten  years  ;  sounded 
three  years  ago,  but  no  stone  was  found.  Profuse  bleeding  followed, 
and  patient  was  laid  up  in  a  surgical  home  for  six  months,  and  became 
reduced  to  a  skeleton  ;  entirely  dependent  on  catheter  for  three  years. 
Double  vasectomy  by  a  London  surgeon  two  and  a  half  years  ago  with 
no  improvement.  Catheter  used  six  or  seven  times  daily  ;  urine  con- 
tained pus  and  albumin  ;  catheter  introduced  13  inches  before  urine 
flowed.  Prostate  much  enlarged  per  rectum,  bilobed,  soft,  movable; 
easily  felt  bimanually. 

On  January  27,  Sir  William  Thomson  of  Dublin  and  Dr.  Hart  being 


CASES  SUBJECTED  TO  McGILDS    OPERATION        131 

present,  I  removed  the  prostate,  which  weighed  \\  ounces,  entire  in  its 
capsule.  There  was  an  enormous  outgrowth  in  the  bladder,  the  size  and 
shape  of  a  large  pear,  springing  from  both  lobes.  Time  occupied, 
five  minutes.  Much  shock  after  operation,  though  no  bleeding.  After 
this,  uninterrupted  recovery.  Urine  passed  per  urethram  February  9  ; 
wound  dry  next  day.  Went  home  in  good  health  February  27  ;  able  to 
pass  and  retain  urine  'better  than  ever  before,'  as  he  said.  On  March  16. 
1906,  he  wrote  :  '  I  have  no  troubles  with  the  urine  ;  I  am  not  even 
disturbed  at  night.  I  consider  the  operation  an  inspiration,  and  the 
result  a  great  blessing.' 

Case  100. — Gentleman,  aged  sixty-eight,  consulted  me  March  17, 
1904,  on  the  advice  of  Dr.  F.  Rodgers,  Cambridge,  and  Dr.  W.  Wooll- 
combe,  Plymouth.  Catheter  employed  for  six  years,  entirely  dependent 
thereon  for  two  years.  Double  vasectomy  by  another  surgeon  in  1901, 
with  no  relief,  but  followed  by  orchitis.  Prostate  enlarged  per  rectum, 
movable  ;  felt  bimanually.  Urine  kept  fairly  clear  by  washing  bladder 
daily,  but  contained  pus.  Operation  arranged  for,  but  subsequently 
postponed  owing  to  severe  attack  of  pneumonia. 

On  May  25  I  removed  the  prostate  entire  in  its  capsule,  Dr.  Wooll- 
combe  assisting,  Colonels  J.  Moorehead  and  J.  Anderson.  I. M.S.,  and 
Dr.  Deighton,  Cambridge,  being  present.  Thumb-like  outgrowth  from 
left  lobe  acting  as  a  ball-valve  to  the  urethral  orifice.  Weight  of 
prostate,  1]  ounces  ;  time  occupied,  five  and  a  half  minutes.  Urine 
passed  naturally  June  7  ;  wound  dry  June  II.  On  June  21  he  left  the 
surgical  home  able  to  pass  and  retain  urine  as  well  as  ever  he  did.  <  In 
March  16,  1906,  he  wrote  :  '  I  am  extraordinarily  well.  Waterworks  all 
right  ;  in  fact,  1  have  never  got  cause  to  think  about  them,  whereas  for 
lung  years  before  I  never  thought  of  anything  else.' 

3.  Cases  previously  operated  on  by  McGill's  Method  of 
Partial  Prostatectomy. 

Case  48.  Gentleman,  aged  sixty-two,  consulted  me  May  25,  1903,  on 
the  ad\  ice  of  I  )r.  Vickers,  Wellington,  Salop.  Prostatii  sj  mptoms  for  ten 
years,  with  recurrent  haemorrhage  during  the  last  five.  Profuse  haemorrhage 
on  July  13,  1902,  followed  by  retention  of  urine,  which  was  relieved  by 
(  atheter.  The  haemorrhage  re<  urring,  and  difficulty  being  experienced 
in  introducing  the  catheter,  on  July  16  the  bladder  was  opened  supra 
pubically  by  a  well-known  provincial  surgeon,  who  writes  thai  he  removed 
.1  '  middle  lobe '  lying  over  the  inner  orifice  ol  the  urethra,  larger  than  a 
tangerine  1  range.  <  >w  ing  to  the  weak  condition  of  the  patient,  he  did  not 
consider  it  advisable  to  attempt  total  removal  <>f  the  prostate.  Convales 
cence  was  retarded   by  a  large  gluteal  abscess,  the  suprapubic  wound 

-2 


132         CASES  SUBJECTED  TO  McGILVS  OPERATION 

taking  some  three  months  to  heal.  After  five  weeks  the  wound  again  broke 
down,  the  fistula  remaining  continuously  open  ever  since.  Patient  in  a 
very  miserable  condition,  passing  urine  every  hour  by  day  and  night, 
almost  entirely  by  the  fistula.  Much  pain,  with  periodical  discharge  of 
large  quantities  of  pus,  'as  if  an  abscess  had  burst,'  as  the  patient 
described  it.  General  health  very  bad  ;  numerous  unhealthy  sores  all 
over  the  body,  due  to  absorption  of  septic  matter.  Prostate  much 
enlarged^';-  rectum,  soft,  tense,  and  more  or  less  movable. 

On  June  2,  Mr.  C.  Braine  being  the  anaesthetist,  I  removed  the 
remainder  of  the  prostate,  weighing  3^  ounces.  The  operation  was  very 
prolonged  (ij  hours).  A  very  careful  dissection  was  necessary  to  avoid 
opening  the  peritoneum,  which  was  bound  down  to  the  scar.  The  hard 
scar  tissue  around  the  fistula  rendered  the  abdominal  wall  unyielding, 
so  that  the  finger  with  great  difficulty  reached  the  prostate.  And. 
finally,  the  prostate  itself  was  matted  with  the  bladder  walls  and  the 
enveloping  sheath,  so  that  great  difficulty  was  experienced  in  its  enuclea- 
tion ;  indeed,  it  was  removed  in  four  separate  pieces.  There  was,  how- 
ever, little  bleeding,  though  the  shock  was  severe  and  lasted  for  some 
hours. 

With  the  exception  of  a  bilious  attack  a  week  after  operation,  the 
patient  made  an  uninterrupted  recovery.  He  passed  some  urine 
naturally  fune  16,  and  the  suprapubic  wound  was  quite  closed  June  23. 
On  July  12  he  left  for  the  seaside  in  excellent  health,  retaining  and  pass- 
ing his  urine  naturally.  On  April  5,  1904,  he  wrote  :  'I  am  still  going 
on  well,  and  am  in  excellent  health,'  in  which  state  he  remained  till  a 
short  time  before  his  death  on  November  23,  1905,  from  an  abdominal 
operation.  A  relative  wrote  me  on  December  3,  1905  :  'It  (his  death) 
had  nothing  to  do  with  the  old  trouble  at  all ;  he  had  a  twist  in  the 
bowel' 

This  case  presents  a  practical  example  of  the  unsatisfactory  results 
attendant  on  McGilFs  operation,  or  partial  prostatectomy  ;  also  of  the 
difficulties  that  may  be  encountered  in  attempting  subsequent  removal 
of  the  main  portion  of  the  prostate  which  is  left  behind. 

Case  63. -On  October  20,  1903,  I  was  summoned  to  Birmingham  to 
see,  in  consultation  with  Dr.  M.  Hallwright,  a  gentleman,  aged  sixty-six, 
who  had  suffered  from  prostatic  symptoms  for  seven  years,  extremely 
distressing  for  the  last  three.  Early  in  1903  he  became  suddenly  much 
worse,  and  a  catheter  was  passed  by  a  surgeon.  This  was  followed  by 
much  constitutional  disturbance  and  pyrexia,  in  consequence  of  which 
the  catheter  was  not  persisted  in.  In  February  he  had  continued  pain, 
constant  spasm  with  offensive  urine.  The  physician  then  in  charge 
found  tube  casts,  and  considered  that  pyelitis  had  set  in.  Complete 
retention  on  March  1,  for  which  the  bladder  was  opened  suprapubically 


CASES  SUBJECTED  TO  McGILVS  OPERATION         133 

by  a  well-known  surgeon,  and  a  prominent  portion  of  the  prostate  in  the 
bladder,  weighing  \  ounce,  removed.  Although  relieved  to  some 
extent,  patient  was  never  free  from  bladder  spasm,  though  suprapubic 
drainage  was  kept  up,  and  after  some  months  he  drove  out,  wearing  a 
urinal.  No  urine  had  passed  naturally  since  the  operation.  Orchitis 
also  supervened,  and  the  straining  and  discomfort  of  the  urinary  appara- 
tus became  so  wearing  that  complete  removal  of  the  prostate  was  con- 
templated. It  was  with  this  view  that  1  was  called  in.  I  found  the 
prostate  considerably  enlarged  per  rectum,  bilobed,  elastic,  and  movable, 
and  I  considered  it  one  capable  of  being  removed.  The  patient  was  of  a 
nervous  temperament,  extremely  thin  and  worn  from  his  constant  suffer- 
ings, but  wiry. 

For  various  reasons  it  was  considered  inadvisable  to  bring  the  patient 
to  London,  so  on  October  24  I  operated  at  Birmingham — Dr.  llaynes, 
anesthetist,  Dr.  Hallwright  assisting,  and  Dr.  C.  Nichols  being  present. 
Having  opened  up  and  enlarged  the  suprapubic  fistula,  I  found  the  right 
lobe  of  the  prostate  somewhat  prominent  in  the  bladder,  and  the  enuclea- 
tion of  this  portion  was  quite  easy.  The  left  lobe,  however,  was  matted 
by  cicatricial  tissue  with  the  bladder,  the  result  of  the  previous  operation, 
and  the  enucleation  of  this  portion  was  effected  with  considerable  diffi- 
culty, much  force  being  necessary  to  separate  it  from  the  surrounding 
tissues.  Eventually  the  prostate,  or,  rather,  what  remained  of  it  from  the 
previous  operation,  came  away  in  one  mass,  weighing  i^  ounces.  There 
was  little  bleeding  or  shock.  I  saw  the  patient  with  Dr.  Hallwright 
several  times  during  the  ensuing  three  weeks.  He  continued  to  make 
favourable  pro-res^,  though  he  bad  several  rises  <>f  temperature.  On 
November  15  patient  passed  3$  ounces  of  urine  naturally,  and  on 
November  22  the  wound  was  completely  closed.  On  December  6 
Dr.  Hallwright  wrote  :  '  The  patient  is  better  than  he  has  been  for  y< 
and  gains  strength  daily.  He  says  the  water  is  beautiful  and  takes  no 
time  in  passing.'  I  have  to  acknowledge  the  devotion  and  skill  with 
which  the  after-treatment  was  carried  out  by  Dr.  Hallwright,  and  which 
largely  contributed  to  the  successful  result. 

This  gentleman  is  now  in  excellent  health,  at  the  head  of"  a  great 
business.  On  December  20,  1 905,  he  wrote  :  '1  am  keeping  very  will, 
tii'    from  the  trouble  of  which  you  relieved  mc' 

I   \-i  72. --H.  1' ,  aged  fifty-nine,  admitted  to  St.  Peter's  Hospital 

December  5,  1903,  with  the  usual  symptoms  of  enlarged  prostate.  This 
patient  had  been  operated  on  by  another  surgeon  in  April.  1901,  by 
McGUTs  method;  an  enlarged  'middle  lobe'  of  the  prostate  being 
removed.  The  suprapubic  wound  did  not  heal  till  January,  1902,  when 
the  sinus  was  excised  and  cauterized.  Since  then,  increasing  paii 
frequency  of  micturition.     Cathetei    passed  nightly,  after  which  In 


134  CASES  SUBJECTED  TO  McGILLS  OPERATION 

five  or  six  hours'  sleep  :  at  other  times  had  to  urinate  every  two  hours. 
Residual  urine,  8  ounces,  alkaline,  fetid,  contained  much  pus.  Prostate 
enlarged  per  rectum;  rounded,  tense;  fairly  movable.  Cystoscopy  on 
December  9,  1903,  showed  the  prostate  enlarged  and  rounded  on  the  left 
side,  irregularly  jagged  on  the  right.  A  mass  of  the  muco-pus  covered 
the  trigone,  and  in  this  was  embedded  a  phosphatic  calculus,  which  was 
removed  by  litholapaxy.  The  bladder  was  washed  out  daily,  with  the 
result  that  the  urine  became  acid,  but  there  was  no  diminution  in  the  pus 
or  frequency. 

On  December  16,  Mr.  Bickersteth  of  Liverpool  and  others  being 
present,  I  removed  the  prostate.  There  was  considerable  difficulty  in 
opening  the  bladder  suprapubically,  owing  to  the  scar  tissues  being 
matted  together,  and  still  greater  difficulty  in  enucleating  the  prostate, 
owing  to  the  inflammatory  adhesions,  resulting  from  the  previous  opera- 
tion, between  the  inner  margins  of  the  prostate  and  the  walls  of  the 
bladder,  though  the  gland  came  away  readily  from  the  triangular  ligament. 
A  portion  of   the  prostatic   urethra   came  away  adherent   to  the  gland. 


Fig.  54. — Prostate,  weighing  \\  Ounces,  removed  from  Patient 
aged  Fifty-nine  (Case  72). 

A,  Smooth  nodular  left  lobe  ;   B,  jagged  right  lobe,  result  of  portion  having 
been  previously  removed  by  McGill's  operation. 

Uninterrupted  recovery.  The  wound  was  closed  December  29,  thirteen 
days  after  the  operation.  The  patient  is  now  quite  well,  able  to  retain 
and  pass  his  urine  as  well  as  he  ever  did. 

The  prostate  (Fig.  54),  which  weighs  \\  ounces,  is  jagged  along  the 
posterior  aspect  of  the  right  lobe,  where  it  was  adherent  to  and  matted 
with  the  bladder  wall. 


CASES  SUBJECTED  TO  McGILLS  OPERATION         135 

This  is  the  third  case  in  which  my  operation  of  complete  enucleation 
of  the  prostate  has  been  entirely  successful  after  McGill's  operation  had 
failed.  The  previous  operator  in  this  case  has  persistently  in  his  writings, 
and  otherwise,  minimized  and  misrepresented  the  nature  and  scope  of  my 
operation,  as  being  identical  with  McGill's.  It  is  the  irony  of  fate  that 
this  case,  in  which  McGill's  operation  performed  by  him  had  entirely 
failed  to  bring  relief  to  the  patient,  should  have  fallen  into  my  hands  to 
be  completely  cured  by  total  extirpation  of  the  prostate. 

Cask  125. — G.  C -,  aged  seventy,  admitted  to  St.  Peter's  Hospital, 

September  18,  1004,  completely  dependent  on  the  catheter  from  prostatic 
enlargement.  Had  been  operated  on  in  November,  1903,  in  another 
London  hospital,  the  house-surgeon  of  which  kindly  supplied  the  following 
notes  : 

'  November   26,   1903.      Mr.   operated  by    suprapubic   opening  : 

brought  bladder  to  surface  and  fixed  it  to  abdominal  wall  by  two  lateral 
sutures.  Bladder  was  opened,  and  a  small  vesical  tumour  found  block- 
ing the  internal  meatus.  Mucous  membrane  opened  and  a  tumour  the 
size  of  a  walnut  shelled  out,  adenomatous  in  substance.  Drainage-tube 
inserted  and  catheter  lodged.  December  12.  Abdominal  wound  closed. 
December  16.  Wound  broke  down,  urine  discharging.  January  1.  1904. 
Patient's  condition  not  being  improved,  he  was  again  taken  to  the  theatre, 
wound  opened,  and  the  internal  meatus  found  freely  patent  to  catheter 

passed    through    it.     In   view  of  this    Mr.   determined    not    to   do 

anything  further.      Bladder  appeared  to  be  atonic.' 

Since  this  time  patient  had  been  obliged  to  use  a  catheter  to  draw  off 
his  urine,  usually  four  time-  daily,  though  never  employed  before  the 
operation.  Prostate  enlarged  per  rectum^  bilobed,  soft,  and  movable; 
and  by  the  cystoscope  both  lobes  were  seen  somewhat  prominent  in  the 
bladder,  the  spa<  e  between  them  being  ragged,  the  result  of  the  previous 
operation.      Pulse  irregular,  but  no  bruit  detected. 

On  September  21,  1904,  I  enucleated  the  prostate,  weighing  1  |  ounces, 
with  some  difficulty,  owing  to  the  adhesions  caused  by  the  previous  opera- 
tion ;  rather  more  bleeding  than  usual. 

Uninterrupted  recovery,  with  the  exception  of  slight  orchitis;  wound 
closed,  and  all  the  urine  passed  naturally  October  6;  discharged  cured 
October  24.  This  patient  presented  himself  at  the  hospital  afe*  days 
ago  in  perfect  health,  able  to  pass  and  retain  urine,  which  was  normal, 
as  well  as  he  ever  did.  I  introduced  a  catheter,  but  found  no  residual 
urine. 

Cas]     211.     On  July,  28,   1905,  a  gentleman,  aged  sixty-eight,  ■ 
from  Paris  to  consult  me.    In  November,  [904,  suprapubic  pros tatectomj 
had   been   performed    by  an  eminent   Swiss  surgeon,  but    >  permai 

fistula    had   remained,  the  whole  of  the  mine  passing  by  this  route  cm  epi 


136      CASE  SUBJECTED  TO  PERINEAL  PROSTATECTOMY 

when  a  catheter  was  tied  in  the  urethra.  Urine  alkaline,  containing 
much  pus  and  mucus,  with  a  putrid  odour.  Per  rectum  I  could  distinctly 
feel  that  a  portion  of  the  prostate  had  been  left  behind,  placed  high  up. 
As  I  was  starting  on  my  holiday  the  operation  was  postponed  till 
September,  when  the  patient  returned  from  France.  He  was  then  in  the 
same  condition,  wearing  a  catheter  with  urinary  apparatus. 

On  September  13,  1905,  I  enlarged  the  fistula,  pared  its  margins,  and 
removed  3  phosphatic  calculi  weighing  203  grains  The  orifice  of  the 
bladder  was  stenosed,  being  kept  open  by  the  catheter,  and  there  was  a 
beaded  fringe  round  this  consisting  mainly  of  three  nodules  of  prostate, 
each  the  size  of  a  large  cherry.  I  burst  open  the  stenosed  orifice  with 
my  finger,  and  enucleated  the  nodules  of  prostate.  Much  difficulty  was 
experienced  in  separating  them  from  the  mucous  membrane  of  the 
bladder  owing  to  inflammatory  adhesions  ;  and  the  process  was  a  lengthy 
one,  the  operation  lasting  three-quarters  of  an  hour. 

The  wound  was  extremely  slow  in  closing,  partly  owing  to  the  debili- 
tated and  depressed  state  of  the  patient,  but  mainly  to  the  fact  that  there 
was  a  prolapse  of  the  posterior  wall  of  the  bladder  through  the  fistula,  the 
result  of  the  previous  operation.  The  lower  wall  of  the  fistula  was 
15  inches  deep,  but  the  upper  only  \  inch  deep  to  its  junction  with  the 
mucous  membrane  of  the  bladder,  so  that  it  would  have  been  dangerous 
to  pare,  or  extensively  scrape,  the  sides  of  the  fistula  lest  the  peritoneum 
should  be  entered.  By  the  end  of  December  the  patient  left  for  the 
seaside  with  an  extremely  narrow  fistulous  opening,  the  urine  being  quite 
normal.  He  subsequently  went  to  Paris,  where  my  friend,  Professor 
Hartman,  successfully  pared  and  stitched  together  the  margins  of  the 
fistula,  and  I  am  pleased  to  learn  that  the  patient  is  now  passing  his 
urine  naturally. 

4.  Case  previously  subjected  to  Perineal  Prostatectomy. 

CASE  199. — Gentleman,  aged  sixty-three,  seen  in  consultation  with 
Dr.  D.  W.  Patterson  (Newcastle-on-Tyne),  March  1,  1904.  Prostatic 
symptoms  for  ten  years.  Residual  urine,  a|  ounces  ;  prostate  much 
enlarged  per  rectiwi,  particularly  the  right  lobe,  soft,  smooth,  movable, 
and  felt  bimanually.  The  case  was  considered  a  most  favourable  one 
for  removal  of  the  prostate,  which  was  advised.  Other  counsels, 
however,  prevailed.  Acute  retention  set  in  in  July,  followed  by  severe 
cystitis.  Perineal  prostatectomy  was  performed  by  another  surgeon 
in  September,  1904.  Patient  apparently  did  well  till  the  perineal  wound 
healed,  when  there  was  great  difficulty  in  micturition  from  stricture, 
which,  however,  yielded  to  dilatation.  Since  that  time  he  had  not  been 
able  to  empty  his  bladder,  the  residual  urine  varying  from  4  to  14  ounces. 


CASE  SUBJECTED  TO  BOTTINPS  OPERATION         137 

Bladder  emptied  by  catheter  and  washed  out  daily  for  months,  as  the 
urine  contained  much  muco-pus. 

I  saw  the  patient  again  with  Dr.  Patterson,  June  26,  1905.  I  drew  off 
10  ounces  residual  urine,  containing  much  pus  and  mucus.  I  could  find 
no  trace  of  the  prostate  per  rectum,  but  on  bimanual  examination  I  felt 
a  lump  the  size  of  a  walnut  in  the  median  line  at  the  neck  of  the  bladder, 
which  was  regarded  as  a  portion  of  the  prostate  left  behind. 

On  June  29,  Mr.  C.  Braine  being  anaesthetist,  I  opened  the  bladder 
suprapubically.  The  inner  orifice  of  the  urethra  was  found  stenosed  and 
surrounded  by  a  beaded  prostatic  collar,  from  the  base  of  which  a  teat-like 
process  projected  into  the  bladder.  This  collar  was  forcibly  burst  open 
by  the  finger,  and  the  remaining  prostatic  substance  scraped  out  of  the 
sheath  by  the  finger-nail.  This  was  a  slow  procedure,  as,  though  the 
collar  presenting  in  the  bladder  was  easily  detached  from  the  mucous 
membrane,  the  anterior  portions  of  the  prostatic  tissue  were  stoutly 
adherent  to  the  sheath  from  cicatricial  union,  the  result  of  the  perineal 
prostatectomy.  The  remaining  portion  of  the  prostate  came  away 
piecemeal,  and  weighed  g  ounce.  After  its  removal  the  sheath  felt  quite 
smooth,  and  the  neck  of  the  bladder  gaped  widely  open.  There  was 
much  more  bleeding  than  in  an  ordinary  case  of  enucleation  of  the 
prostate  entire. 

Recovery,  though  rather  slow,  was  uninterrupted.  Some  urine  was 
passed  per  urethram  on  July  15,  and  wholly  in  this  way  on  July  24.  <  >n 
March  17,  1906,  he  writes:  'The  operation  performed  by  you  in  June 
last  has  remained  a  perfect  success.  I  can  retain  and  expel  the  contents 
of  the  bladder  at  discretion.  The  result  is  the  more  remarkable 
because  before  coming  to  you  I  had  been  the  victim  ol  a  failure  on  the 
part  of  another  surgeon,  whose  operation  of  September,  1904,  had  been 
absolutely  valueless,  causing  me  to  fear  that  no  successful  result  was 
possible.' 

5.  Case  previously  subjected  to  Bottini's  Operation. 

<  asi    [20.     A  distinguished   Russian  General,  aged  seventy-five,  con 
suited   me   August    4,   1904,  suffering    from    prostatic  symptoms  for  six 
:  completely  dependent  on  the  catheter  for  three  years;  operated 
on  about  three  years  ago  by  the  late  Professoi    Bottini  of  Italy  by  the 
electro-cautery,  but  with  no  improvement.     Since  then   lias  hail  cystitis 
continuously,  for  which  bladder  washed  out  twice  daily.     Mad  consulted 
many  specialists  on  the  Continent  and  in  England,  including   Profi 
Guyon  of  Paris,  with  whose  kind  approval  I  was  approached  with  .1  view 
to  removal  of  the  prostate.     Great   loss  of  flesh  during  past  few   j 
with  some  digestive  troubles;  prostate  enlarged  per  rectum^  bilobed,  very 


138         CASE  SUBJECTED  TO  BOTTINTS  OPERATION 

movable,  felt  bi manually  ;  calculus  detected  by  the  sound  ;  sufferings  so 
severe  that  the  patient  said  he  would  run  any  risk  from  operation  rather 
than  continue  '  catheter  life.'  On  my  advice  he  consulted  Sir  Douglas 
Powell,  who  considered  that  his  constitution  was  sufficiently  sound  to 
stand  operation,  which  had  to  be  postponed  till  after  my  autumn 
holiday. 

On  September  15,  Ur.  Hewitt  being  the  anaesthetist,  I  removed  two 
phosphatic  calculi  suprapubically,  and  then  enucleated  the  prostate. 
This  was  accomplished  with  difficulty,  owing  to  the  cicatricial  adhesions 
between  the  prostate  and  bladder  resulting  from  Bottini's  operation. 
Scarcely  any  bleeding  ;  no  shock.  There  was  no  rise  of  temperature,  and 
satisfactory  progress  was  made,  with  the  exception  of  his  severe  digestive 
troubles,  for  which  Sir  William  Broadbent  saw  him  with  me.  On 
September  24  urine  passed  freely  per  urethram,  but  the  suprapubic 
wound  being  slow  in  closing,  I  tied  in  a  rubber  catheter  on  October  21 
for  five  days,  when  the  suprapubic  wound  was  firmly  closed,  and  the 
urine  passed  naturally  with  perfect  ease.  On  November  5  patient  left 
for  the  Riviera  in  good  health,  able  to  pass  and  retain  his  urine  better 
than  he  ever  did  before.  On  January  16,  1905,  I  heard  from  him  that 
his  urine  was  quite  clear,  and  that  his  digestive  troubles  had  practically 
disappeared. 


LECTURE  VII 

RESULTS  OF  THE  OPERATION  OF  TOTAL  ENUCLEATION 
OF  THE  PROSTATE,  WITH  SOME  CONCLUDING 
REMARKS 

Excluding  undoubted  instances  of  carcinoma,  I  have  now 
performed  my  operation  of  total  enucleation  of  the  adeno- 
matous prostate  in  312  cases,  the  patients  varying  in  age 
from  forty-nine  to  eighty-seven  years,  the  average  age  being 
sixty-eight  years  ;  and  the  prostates  weighing  from  -\  ounce 
to  14]  ounces,  with  an  average  weight  of  2'}  ounces. 

The  vast  majority  of  the  patients  had  been  entirely 
dependent  on  the  catheter  for  periods  varying  up  to  twenty- 
four  years.  Nearly  all  of  them  were  in  broken  health, 
and  many  were  apparently  moribund  when  the  operation 
was  undertaken.  The  great  majority  of  them  were,  indeed, 
reduced  to  such  a  wretched  condition  that  existence  was 
simply  unendurable.  Few  of  them  were  free  from  one  or 
more  grave  complications,  such  as  cystitis,  stone  in  tin- 
bladder,  pyelitis,  kidney  disease,  diabetes,  heart  dise 
thoracic  aneurism,  chronic  bronchitis,  paralysis,  single, 
double,  or  even  treble  hernia,  hemorrhoids,  and  in  a  lew 
instances  cancer  of  some  other  or^an  than  the  prostate. 
Such,  thin,  were  the  unpromising  conditions  under  which 
the  operation  was  undertaken. 

In    connection    with     these      ;i_'     operations     there    were 
22  deaths,  the  remaining  290  casts  being   successful.     And 

139 


140  RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

when  I  speak  of  success  I  mean  complete  success,  the 
patients  regaining  the  power  of  retaining  and  passing  urine 
naturally  without  the  aid  of  a  catheter  as  well  as  they  ever 
did.  There  are  no  half-measures  about  this  operation.  The 
patient  can  be  assured  beforehand  that  if  he  is  prepared  to 
accept  the  comparatively  small  risk  attaching  thereto,  he 
can,  with  absolute  certainty,  look  forward  to  a  complete 
cure.  In  no  instance  has  the  patient  failed  to  regain  the 
power  of  voluntary  micturition  without  the  aid  of  a 
catheter.  There  has  been  no  instance  of  relapse  of  the 
symptoms ;  on  the  contrary,  lapse  of  time  only  seems  to 
consolidate  the  cure.  In  no  case  has  there  been  contraction 
at  the  seat  of  operation  leading  to  organic  stricture ;  nor  has 
there  been  any  instance  of  a  permanent  fistula  remaining. 
In  very  few  instances  have  distinct  symptoms  of  septicaemia 
supervened. 

Considering  that  in  nearly  the  whole  of  the  cases  the  urine 
was  septic,  and  in  many  putrid,  before  the  operation,  this 
comparative  absence  of  septicaemia  is  remarkable.  To 
what  are  we  to  attribute  this  immunity  ?  No  matter  how 
carefully  the  bladder  is  irrigated,  it  is  quite  impossible  to 
keep  the  wound  thoroughly  aseptic.  It  must  be  remembered 
that  a  very  large  proportion  of  aged  men  succumb  to 
septicaemia  on  entering  on  what  is  commonly  termed 
'  catheter  life.'  Probably  those  that  survive  become  more  or 
less  immune  by  gradual  absorption  of  toxins  from  the  septic 
urine  that  prevails  sooner  or  later  in  all  cases  of  habitual 
employment  of  the  catheter. 

The  causes  of  death  are  as  follows  : 

(a)  Seven  cases  from  uraemic  symptoms,  at  intervals  vary- 
ing from  three  to  thirty-nine  days  after  operation.  In  all  of 
these  cases  the  patients  were  suffering  from  pyelo-nephritis, 
or  other  chronic  disease  of  the  kidneys,  resulting  from  the 
prostatic  obstruction. 


RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE   14 

(6)  Three  from  heart  failure — viz.,  one  six  hours  after 
operation  in  a  patient  aged  seventy-four,  who  had  been 
entirely  worn  out  by  fifteen  years  of  intense  suffering  ;  one 
twelve  days  after  operation,  the  necropsy  revealing  aortic 
incompetency  and  interstitial  nephritis ;  and  one,  aged 
eighty-six,  on  the  third  day,  whose  case  was  complicated  by 
cancer  of  the  bladder. 

(c)  Two  from  septicaemia,  thirteen  and  thirty-five  davs 
respectively,  after  operation,  the  necrops\  revealing  extensive 
interstitial  nephritis  in  the  latter. 

(d)  Two  from  mania,  after  the  wounds  had  practically 
healed,  the  mania  in  one  instance  being  hereditary,  and  having 
set  in  before  operation. 

(e)  Two  from  liver  disease,  believed  to  be  malignant, 
fifteen  and  nineteen  days  respectively,  after  operation.  One 
was  complicated  by  a  large  vesical  calculus,  cystitis,  and 
pyelitis.  The  other  was  deeply  jaundiced  at  the  time  of 
operation,  which  was  undertaken  as  almost  a  forlorn  hope 
to  relieve  terrible  suffering  (the  prostate  was  found  to  be  of 
a  dark  yellow  colour  from  the  bile-pigment).  Both  had  for 
two  years  suffered  from  gastro-hepatic  symptoms. 

(J)  One  from  shock  seven  hours  after  operation. 

(g)  One  from  exhaustion  thirty-three  days  after  operation, 
the  kidneys  being  extensively  diseased. 

(h)  One  from  heat-stroke,  on  the  tenth  day,  when  quite 
convalescent  from  the  operation. 

(»)  One  from  pneumonia  seven  days  after  operation.  Two 
days  before  operation  the  patient  had  travelled  a  long  journey 
in  snowy  weather,  and  it  is  believed  that  the  pneumonia  was 
the  result  of  a  chill  thus  contracted. 

(;')  One  from  acute  bronchitis  thirty  hours  ofter  operation. 
This  patient  was  suffering  from  an  enormous  naso-phur\  n- 
geal  growth,  the  removal  of  which  had  been  twice  attempted. 


142    RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

The  bronchitis  was  attributed  to  the  anaesthetic  acting  on 
an  irritable  mucous  membrane. 

(k)  One  suddenly  on  the  fifth  day  after  pulmonary 
embolism.  I  saw  the  patient  an  hour  before  death,  and  he 
had  had  no  unfavourable  symptom  since  the  operation. 

Though  these  deaths  are  recorded  in  connection  with  the 
operation,  it  will  be  observed  that  in  not  more  than  one  half 
of  the  number  can  the  fatal  result  be  attributed  directly 
thereto,  the  remaining  deaths  being  due  to  diseases  incident 
to  old  age.  This  operation  is  comparable  to  none  other  in 
surgery,  owing  to  the  advanced  age  to  which  it  is  necessarily 
confined,  and  the  broken-down  constitutions  of  the  patients 
from  prolonged  suffering;  and  in  judging  of  the  mortality 
connected  therewith  we  must  not  lose  sight  of  the  fact  that 
during  the  period  of  after-treatment  and  convalescence  men 
of  this  age  are  peculiarly  liable  to  be  carried  off  suddenly  by 
disease  entirely  unconnected  with  the  operation,  the  occur- 
rence, however,  vitiating  the  results  from  a  statistical 
point  of  view. 

But  even  if  we  accept  all  the  deaths  in  connection  with 
the  operation,  this  would  give  only  a  mortality  of  about  7  per 
cent.,  which  is  much  less  than  the  mortality  from  lithotomy 
in  all  ages  combined  (12J  per  cent,  according  to  statistics 
collected  by  Sir  Henry  Thompson),  and  about  one-fifth  of 
the  mortality  from  lithotomy  in  the  corresponding  ages 
(33^  per  cent,  according  to  Sir  Henry  Thompson).  If  the 
operation  were  undertaken  in  selected  cases  only — cases  in 
which  the  general  health  was  unimpaired — the  mortality 
might  be  still  further  much  reduced ;  but  any  such  restriction 
is  in  my  opinion  unjustifiable,  as  it  would  have  the  effect  of 
excluding  five-sixths  of  the  patients  who  at  present  seek 
relief  from  this  operation.  As  the  operation  becomes  more 
widely  known  and  more  popular  patients  will  no  doubt  seek 
relief  therefrom  at  an  earlier  period  of  the  disease,  whilst 


RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE    143 

their  constitutions  arc  sound,  and,  above  all,  the  kidneys 
unimpaired,  with  a  much  greater  prospect  of  success.  It  will 
be  observed  that  in  a  large  proportion  of  the  fatal  cases  death 
was  due  to  chronic  forms  of  kidney  disease  incident  to  so-called 
'  catheter  life.'  It  therefore  behoves  the  patient  to  seek,  and 
it  is  incumbent  on  his  medical  adviser  to  urge,  operation 
whilst  the  kidneys  are  still  sound,  before  the  complications 
arising  from  '  catheter  life '  set  in,  resulting  in  destruction 
of  the  kidneys,  or  impairment  of  their  functions.  Increased 
experience  and  dexterity  in  operating,  improvement  in  the 
details  of  the  after-treatment,  and  a  greater  perfection  in  the 
nursing  are  all  factors  that  will  undoubtedly  tend  to  reduce 
still  further  the  death-rate.  I  have  recently  had  a  consecu- 
tive series  of  thirty-seven  operations  without  a  death. 

I  submit  that  the  results  of  this  operation — so  subversive 
of  all  preconceived  ideas  regarding  the  enlarged  prostate,  so 
revolutionary  in  its  effects,  so  complete  and  permanent  in  its 
(lire — are  truly  remarkable.  They  are  far  beyond  anything  I 
could  have  hoped  for  at  its  inception.  I  believe  that  I  shall  not 
be  accused  of  exaggeration  when  I  state  that  all  previous 
so-called  methods  of  radical  cure  of  enlarged  prostate  were 
utterly  unsatisfactory,  and  that  catheterism,  though  hitherto 
the  least  objectionable  mode  of  treatment  in  the  majority  of 
cases,  is  certain  sooner  or  later  to  terminate  in  cystitis  and 
other  dangerous  complications.  The  successful  results 
obtained  in  this  large  series  of  cases  of  total  enucleation  of 
the  enlarged  prostate  encourage  us  in  the  hope  that  we 
have  at  last  arrived  at  a  rational  and  practical  method  <>t 
dealing  with  one  of  the  most  painful,  pathetic-,  ami  fatal 
disea 

1  here  i^,  perhaps,  no  expression  which  one  hears  and  sees 

more   constantly   made   use   of  in   connection    with    prostatic 
cases  than   'atony   of   the    bladder.'     The    history   of    tl: 
cases  goes    far    to    prove,  I    submit,  thai    no   such    condition 


144   RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

exists,  even  in  the  most  advanced  instances  of  the  disease  ; 
and  that  even  when  complete  catheterism  has  prevailed  for 
many  years  the  bladder  walls  retain  their  expulsive  power. 
Indeed,  they  are  constantly  making  involuntary  efforts  to  get 
rid  of  the  urine,  which  is  merely  kept  back  by  the  mechanical 
blockage  of  the  passage  by  the  enlarged  prostate.  And 
though  in  the  early  stages  of  the  disease  a  so-called  '  middle 
lobe  '  may  impede  the  flow,  I  am  convinced  that  in  the  later 
stages  the  lateral  pressure  exerted  on  the  canal  is  the  main 
cause  of  the  obstruction. 

One  of  the  most  remarkable  features  of  this  operation  is 
the  complete  restoration  of  the  power  of  voluntary  micturi- 
tion after  habitual  catheterism  had  been  employed  for 
lengthened  periods.  It  may  be  of  interest  to  quote  the 
opinions  of  two  eminent  surgeons,  one  in  this  country  and 
one  on  the  Continent,  as  to  the  possibility  of  this  occurring. 
The  late  Sir  H.  Thompson,  in  the  last  edition  of  his  'Diseases 
of  the  Urinary  Organs,'  writes  : 

'  When  it  has  been  necessary  to  practise  habitual  cathe- 
terism for  retention  from  enlarged  prostate  during  a  period 
of  one  or  two  years,  the  coats  of  the  bladder  lose  their  power 
and  are  incapable,  I  believe,  of  regaining  it  in  almost  any 
case  after  that  lapse  of  time,  and  would  fail  to  expel  their 
contents  even  supposing  the  obstruction  to  be  entirely 
removed.  There  is  good  ground  for  believing  that  no 
operation  would  restore  a  status  quo,  on  account  of  our 
inability  to  restore  the  expelling  function  to  a  bladder  which 
has  long  ceased  to  exercise  it.' 

And  M.  Guyon  in  his  '  Lecons  Cliniques  '  (1888)  writes : 

'  Voyez,  en  avant,  ces  lourdes  masses  qui  representent  les 
lobes  lateraux,  fortement  appliques  l'un  contre  l'autre  et  qui 
opposent  un  obstacle  certainement  plus  considerable  que  le 
lobe  moyen  a  l'ecoulement  de  l'urine.  Croyez-vous  qu'il  soit 
jamais  possible  d'en  pratique/  aussi  V ablation  ?     Et  quand  un 


RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE    (45 

tel  prodige  operatoire  deviendrait  realisable,  croyez-vous  que 
la  vessie,  aprcs  avoir  etc  plus  ou  moins  longtemps  soumise  a  la 
iistension, pourrait  recouvrer  son  integrity  anatomiquc  et  fonction- 
nellc ?  Croyez-vous  que  les  lesions  histologiques  dont  sa 
;ouche  musculaire  et  sa  muqueuse  sont  atteintes,  et  celles 
qui  portent  sur  la  substance  renale,  seraient  aussi  susceptibles 
de  retrograder  ?  II  est  evident  que  toutes  ces  lesions,  et 
yous  savez  qu'elles  sont  a  peu  pres  constantes,  memes  des 
le  debut  de  la  maladie,  ne  peuvent  relever  d'aucune  inter- 
vention operatoire,  et  je  puis  ainsi  coucluvc  que  le  traitcment 
radicale  de  V hypertrophic  de  la  prostate  ncxistc  pas  et  ne  saurait 
ixister.' 

The  italics  are  mine.  The  very  decided  opinions  expressed 
by  these  two  distinguished  surgeons — opinions  based  on 
purely  theoretical  grounds — have,  happily,  been  entirely 
falsified  by  the  results  of  these  cases  ;  for  not  only  has  the 
enlarged  prostate  been  ablated  in  each  instance,  but  the 
expulsive  power  of  the  bladder  has  been  completely  restored 
ifter  that  power  had  been  lost  for  periods  varying  from  a 
Few  months  to  twenty-four  years.  It  was,  therefore,  a  source 
if  much  pleasure  and  satisfaction  to  me  to  receive  from 
Sir  Henry  Thompson  a  letter  intimating  his  conversion  to 
my  views  in  the  following  words: 

1  I  am  much  obliged  to  you  for  sending  me  your  lecture, 
ind  cannot  resisl  tin:  evidence  you  have  produced  that  the 
apenitiou  of  total  extirpation  of  the  prostate  is  possible,  and 
ins  led  tn  excellent  results. 

'I  am  surprised  by  the  results  which  you  have  found  in 
your  cases,  of  power  to  empty  tin-  bladder  by  the  natural 
[lowers,  which  were  not  believed  on  <t  priori  grounds  by  my 
Ad  friend  Guyon  and  myself  to  exist.1 

Sir  Henry,  who  was  intensely  interested  in  this  operation, 
ivas  good  enough  to  pay  me  several  visits  tor  tip-  purpose  "t 
examining  the  prostates  removed,  and   I  was  fortunate  in 

in 


146  RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

having  the  aid  of  this  veteran  surgeon  in  the  interpretation 
of  certain  features  connected  therewith. 

The  essential  portion  of  the  operation — that  during  which 
profound  anaesthesia  is  necessary — is  covered  by  the  time 
that  elapses  between  commencing  the  suprapubic  cystotomy 
and  the  delivery  of  the  prostate  from  the  bladder.  It  will 
have  been  observed  that  with  increased  experience  has  come 
increased  rapidity  of  execution.  In  the  early  days  of  the 
operation  it  was  not  unusual  for  this  period  to  extend  to 
twenty  minutes  or  half  an  hour,  or  even  more,  whilst  latterly 
in  ordinary  cases  this  period  is  covered  by  from  two  to  five 
minutes,  and  in  difficult  cases  by  from  eight  to  twelve  minutes. 
There  can  be  no  doubt  that  rapidity  in  operating  is  of  vital 
importance  in  an  operation  of  this  kind,  confined  as  it  is  to 
persons  of  advanced  age,  thus  shortening  the  period  during 
which  full  anaesthesia  is  necessary,  minimizing  the  loss  of 
blood,  and  obviating  shock. 

In  the  correspondence  that  ensued  on  the  publication  of 
my  first  lecture  on  the  subject  of  total  enucleation  of  the 
prostate  in  the  British  Medical  Journal  of  July  21,  1901,  the 
question  was  discussed  as  to  whether,  as  held  by  me,  my 
operation  was  a  complete  prostatectomy,  or,  as  suggested 
by  some,  one  in  which  a  thin  layer  of  the  outer  rim  of  the 
prostate  was  left  behind.  The  question  was,  of  course,  one 
of  purely  academic  interest,  and  could  not  in  any  way 
detract  from  the  practical  merits  of  the  operation,  for  no  one 
could  deny  that  the  results  were  eminently  satisfactory  to 
the  patient. 

The  evidence  on  which  I  based  my  conclusion  that  my 
operation  was  a  complete  prostatectomy  may  be  summarized 
thus :  (1)  The  general  conformation  of  the  specimens 
removed  by  me  indicated  that  they  were  entire  prostates. 
(2)  The  absence  of  any  palpable  prostatic  substance  in  the 
cavity  that  remained  at  the  time  of  operation,  as  felt  between 


RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE  147 

a  finger  in  this  cavity  and  a  finger  in  the  rectum — a  very 
thin  membrane,  consisting  merely  of  the  bowel  and  the 
sheath  of  recto-vesical  fascia,  lying  between  the  points  of  the 
fingers.  (3)  The  absence  of  any  mass  resembling  prostatic 
tissue  in  the  cases  operated  on,  at  any  period  after  the 
operation,  on  examination  by  the  finger  in  the  rectum. 
(4)  When  the  enlarged  prostate  projects  prominently  in  the 
bladder  the  true  capsule  is  at  once  reached  on  scraping 
through  the  mucous  membrane  covering  it  by  the  finger- 
nail. Following  the  outer  aspect  of  this  capsule  by  pushing 
the  finger  through  the  lumen,  outside  the  bladder,  in  the 
plane  between  it  and  the  sheath,  the  organ  is  enucleated 
in  its  capsule.  Now,  if  a  layer  of  prostate  were  left  behind 
extravesically,  this  layer  must  necessarily  extend  intravesi- 
cally  ;  but  in  practice  no  such  layer  is  found  in  the  bladder, 
but  merely  mucous  membrane.  (5)  The  absolute  and 
complete  relief  of  the  symptoms  after  operation,  no  matter 
how  man}'  years  the  patient  had  been  dependent  on  the 
catheter.  (6)  But  Mr.  Thomson  Walker  has  adduced  the 
most  cogent  evidence  of  all  {vide  Medico-Chirurgical  Transac- 
tion.-, [904,  pp.  404-445),  by  demonstrating  that  no  prostatic 
tissue  is  found  in  specimens  removed  from  the  bodies  of 
persons  on  whom  the  operation  had  been  performed  during 
life.  The  fact  that  occasionally  a  minute  nodule  or  tuft  oi 
prostatic  tissue  is  accidentally  left  behind,  owing  probably 
to  inflammatory  adhesions  between  the  capsule  and  sheath, 
i>  no  proof  that  the  prostate  is  not  enucleable  as  a  whole. 
As  well  might  it  be  argued  that  the  edible  portion  of  an 
orange   is   not    enucleable   entire    from    the    rind,   because 

isionally,  through  under-  or  over-ripeness,  a  small   m 
of  the  pulp  and  capsule  is  left  adherent  to  the  rind. 

In  the  April  number  of  the  Annals  of  Surgery  for  1005. 
Dr.  Eugene  Fuller,  of  New  York,  lays  claim  to  having  been 
the  originator  of  the  operation  which   I  have  described  as 

10 — 2 


148   RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

my  own.  A  similar  claim  was  advanced  by  him  during  the 
controversy  that  ensued  on  the  publication  of  my  first  lecture 
on  the  subject  in  the  British  Medical  Journal  of  July  20,  1901, 
and  its  absurdity  demonstrated  in  the  issue  of  that  journal 
of  August  17,  1901.  I  should  not,  therefore,  consider  it 
necessary  to  refer  to  the  subject  again,  only  that  Dr.  Fuller 
now  publishes  in  support  of  his  contention  a  somewhat 
belated  letter,  dated  February  5,  1905,  written  him  by  Dr. 
Ramon  Guiteras,  of  New  York,  in  which  this  latter  gentle- 
man alleges  that  when  passing  through  London  in  1900  he 
explained  to  me  Fuller's  method  of  operating,  and  his  own 
modification  thereof.  And  then  I  am  accused  of  having 
published  their  combined  method  as  my  own,  without  any 
reference  to  either  of  them  ! 

It  is  true  that  I  did  not  allude  to  the  work  of  either  of 
these  gentlemen,  for  the  simple  fact  that,  as  I  shall  presently 
show,  there  is  no  similarity  between  my  operation  and  that 
described  by  Dr.  Fuller,  and  that  the  '  instruction  '  alleged 
to  have  been  given  me  by  Dr.  Guiteras  exists  only  in  the 
imagination  of  that  gentleman. 

Dr.  Fuller  bases  his  claim  to  having  originated  the  opera- 
tion which  I  regard  as  my  own  on  an  article  published  in 
the  Journal  of  Cutaneous  and  Genito > -urinary  Diseases  of  June, 
1895,  entitled  '  Six  Successful  and  Successive  Cases  of 
Prostatectomy.' 

Turning  to  this  article,  we  find  that  not  alone  was  the 
technique  employed  by  Dr.  Fuller  radically  different  from 
mine,  but  that  his  operation  was  purely  a  partial  prostatec- 
tomy of  the  McGill  type,  bearing  no  resemblance  to  mine. 

In  the  operation  described  by  Dr.  Fuller— (1)  a  perineal 
section  is  made  in  addition  to  the  suprapubic  cystotomy; 
(2)  the  suprapubic  wound  is  closed  by  deep  and  superficial 
sutures ;  (3)  an  attempt  is  made  to  render  the  prostate 
prominent  in  the   bladder   by  pressure   of  the  fist   on  the 


RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE    149 

perineum  ;  and  (4)  cutting  and  crushing  instruments  are 
employed  to  attack  the  prostate,  prominent  amongst  which 
are  (to  use  Dr.  Fuller's  own  words)  '  rough,  serrated-edged 
scissors  with  a  long  handle,'  which  are  used  '  to  cut  through 
the  bladder  wall  '  in  the  region  of  the  urethral  opening — 
'  the  cut  extending  from  the  lower  margin  of  the  internal 
vesical  opening  of  the  urethra  backward  for  ii  inches' — all 
of  which  proceedings  and  accessories  are,  it  will  have  been 
observed,  foreign  to  my  operation. 

Let  us  now'  examine  Dr.  Fuller's  six  cases  in  detail,  to 
ascertain  the  extent  and  nature  of  the  prostatic  substance 
removed  in  each  instance,  and  see  if  this  bears  any  resem- 
blance to  that  removed  by  me,  as  already  described  and 
figured.  The  description  of  what  was  removed  will  be  given 
in  Dr.  Fuller's  own  words : 

Case  A. — '  I  removed  a  large  right  lateral  hypertrophy  and  the 
median  hypertrophy,  which  last  was  moderate.  Owing  to  the  bad 
condition  of  the  patient,  I  did  not  wait  to  remove  a  small  left  lateral 
hypertrophy.' 

Case  B. — '  I  enucleated  in  the  way  described  a  large  collar-like  hyper- 
trophy of  the  prostate.' 

Case  C. — '  I  found  two  large  lateral  hypertrophies.  The  median 
hypertrophy  was  not  marked.  These  hypertrophies  were  all  thoroughly 
enucleated  without  difficulty.' 

( '  \~i  I ).  — •  ( )wing  to  the  age  (forty-eight  years)  of  the  patient  and  the 
small  size  of  the  prostate  as  felt  per  rectum^  it  was  not  thought  ne<  essary 
to  make  a  suprapubic  incision,  the  perineal  route  being  employed.  As 
the  result  of  the  operation  a  very  haul  fibrous  mass,  similar  in  shape  but 
smaller  than  a  hen's  eg^,  was  found  lying  transversely  across  tin  floor 
of  the  bladder  just  at  the  \<  k.    This  was  cut  through  by  the 

knife  in  making  the  perineal  in'  ision.     It  was.  however,  so  fibrous  and 
so  firmly  attai  bed  10  the  1  apsule  of  the  prostate  that  it  was  found  im| >. >-.- 
sible  to  emu  hate  it.  and  it  <  onsequently  had  10  he  cut  away  by  thi 
of  both  the  senat'  d  and  of  prostatectomy  «  utting-fon  1 

Cask  E.     'I  enucleated  two  large  lateral  hypertrop  ether  with 

a  small  median  one,  the  whole  mass  1  oming  away  in  one  p 

Case  F.  'I  enucleated  two  large  lateral  hypertrophies,  together  with 
.1  collar-like  median  hypertrophy,  partially  surrounding  the  urethra.' 

It    is   simply   ludicrous   to   claim  that    these    were   total 


ISO   RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

prostatectomies    resembling    that    described    and    practised 
by  me.      One  (Case  D)  is   a  perineal  operation    pure   and 
simple.       In    one    (Case    A)    Dr.    Fuller   '  did    not   wait    to 
remove  a  small  left  lateral  hypertrophy '  !     They  were  one 
and  all  obviously  partial  prostatectomies,  in  which  nodular 
lumps  of  enlarged  prostate  ('  hypertrophies,'  Dr.  Fuller  calls 
them)  were  removed  from  within  the  capsule,  as  in  McGill's 
operation,  whereas  the  essential  feature  of  my  operation  is 
that  the  prostate  is  enucleated  entire  in  and  with  its  capsule 
out  of  the  enveloping  sheath  of  recto-vesical  fascia.     It  was 
the  discovery  that  this  could  be  accomplished — contrary  to 
the  then  accepted  teachings  of  the  anatomists — that  consti- 
tuted the  essential  novel  feature  in  my  operation.     We  can, 
in  consequence,  approach   our  task — that   of  removing  the 
prostate    entire,  and   the    prostate  only — by    a   simple   and 
scientific  plan  of  campaign,  instead  of  the  crude  and  un- 
scientific  methods    previously  practised  by  McGill  and  his 
imitators,  in  which  scissors,  cutting-forceps,  and  scoops  of 
various  kinds  were  employed  to  cut  and  tear  away  portions 
of  prostate,  leaving  others  behind,  and  frequently  removing 
portions  of  the  bladder  and  other  tissues  beyond  the  limits 
of  the  prostate,  with  such  fatal  results  that  for  some  years 
before    1901,  when    my   operation    was    placed    before   the 
profession,  these  operations  had  been  practically  abandoned. 
The  objects  figured  as  removed  in  Cases  E  and  F  in  Dr. 
Fuller's  series    are  obviously  mangled   masses  of  prostate, 
and  bear  no  resemblance  to  the  cleanly  enucleated  entire 
prostates  figured  by  me,  which,  to  the  number  of  over  300, 
have  been  preserved  in  my  private  collection  or  presented  to 
public  museums,  and  which  have  been  seen  and  examined 
by  scores  of  Dr.  Fuller's  countrymen.     I  challenge  again,  as 
I    have  repeatedly  challenged,  the   production   of  a   single 
authentic  specimen  of  entire  prostate  from  any  museum  in 
the  world,  placed  there  before  the  publication   of  my  first 


RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE  151 

series  of  cases  in  July,  igoi,  with  any  published  illustration 
thereof,  or  description  of  its  having  been  removed  entire  in 
its  capsule.  There  was  no  such  specimen  in  the  great 
Hunterian  Museum  of  the  London  College  of  Surgeons  till, 
at  the  request  of  the  Curator,  I  presented  a  dozen  specimens 
thereto. 

Dr.  Fuller's  idea  of  what  constitutes  a  total  prostatectomy 
is  not  less  quaint  than  his  conception  of  what  constitutes 
a  successful  operation.  Describing  the  condition  of  Case  E, 
he  writes  :  '  Four  weeks  after  the  operation  the  patient  sat 
up,  and  now,  six  weeks  after,  he  walks  about  the  ward  with 
the  aid  of  an  attendant.  The  urine,  now  clear,  still  comes 
through  the  granulating  suprapubic  wound,  which  the  slough 
made  quite  extensive.  There  is  good  expansive  force  in  the 
bladder,  and  with  the  suprapubic  wound  closed  I  feel  that 
urination  will  be  accomplished  without  difhcultv.  The 
uraemic  symptoms  have  not  all  disappeared,  and  at  times  he 
is  drowsy  or  excitable.  It  is  probable  that  in  time  he  will 
succumb  to  his  nephritis,  and  such  is  to  be  expected, 
especially  since,  owing  to  his  poverty,  comparatively  little 
can  be  done  for  him.' 

Let  the  reader  imagine  himself  in  the  position  of  the 
patient,  and  say  if,  under  the  circumstances,  he  would 
regard  this  operation  as  successful  !  But  what  matters  it 
what  the  reader  thinks,  since  Dr.  Fuller  adduces  the  irre- 
proachable testimony  of  Mr.  Mayo  Robson  to  the  effect  that 
it  was  entirely  successful.  In  his  article  in  the  Annals 
Dr.  Fuller  writes :  'Mr.  Robson  conchuk  is  his  reference  to 
me  with  the  remark  :  "  Moreover,  Dr.  Fuller's  cases  referred 
to  above  were  completely  cured."'  I  scarcely  think  that 
even  the  testimon)  of  Mr.  Robson  will  convince  the  reader 
that  this  case  was  either  'successful*  or  'completely  cured.1 
Mr.  Robson  is  evidently  willing  to  extend  to  Dr.  Fuller  that 
elasticity  as  to  the  meaning  of  the  word  'success  '  which  he 


IS 2    RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

employs  in  his  own  statistics  (vide  British  Medical  Journal  of 
September  7,  1901,  p.  627).  I  have  referred  to  this  matter 
merely  to  show  that  Dr.  Fuller's  statements  and  statistics 
have  to  be  taken  with  a  certain  amount  of  reserve. 

Dr.  Fuller  quotes  freely  from  the  letters  of  my  opponents 
in  the  controversy  that  ensued  in  the  British  Medical  Journal 
on  the  publication  of  my  first  four  cases  of  my  operation, 
and  adds  :  '  Anyone  interested  can  read  them.'  Yes  indeed, 
and  interesting  literature  they  will  prove  in  the  light  of 
subsequent  events.  But  considering  the  triumphant  success 
of  my  operation  and  vindication  of  the  views  I  then  enun- 
ciated, I  would  venture  to  suggest  that,  for  the  credit  of  the 
profession,  a  veil  might  be  drawn  over  the  misrepresentations, 
misstatements,  sophistry,  and  venom  with  which  I  was  then 
assailed  when  I  stood  practically  alone — a  fate  which  I  have 
enjoyed  in  common  with  every  pioneer  of  any  great  advance 
in  surgery  or  medicine. 

With  reference  to  the  statement  contained  in  Dr.  Guiteras's 
letter  of  February  5,  1905,  published  by  Dr.  Fuller  in  the 
Annals,  to  the  effect  that  when  in  London  in  1900,  on  his 
way  to  Paris,  where  he  read  a  paper  before  the  International 
Medical  Congress  on  '  The  Present  Status  of  the  Treat- 
ment of  Prostatic  Hypertrophy,'  he  met  me,  and  explained 
Dr.  Fuller's  method  of  operating  and  his  own  modification 
thereof,  I  was  not  previously  aware  that  I  had  had  the 
honour  of  this  gentleman's  acquaintance.  He  does  not 
state  in  his  letter  where  the  interview  took  place,  but 
Dr.  Fuller  supplies  the  omission  by  locating  it  at  St.  Peter's 
Hospital — a  fact  that  would  indicate  that  this  letter  was  not 
the  only  communication  that  passed  between  these  gentlemen 
on  the  subject !  I  presume  that,  like  scores  of  his  country- 
men  —  who  are  always  welcome  —  he  honoured  me  with 
his  presence  in  the  operating  theatre ;  but  I  have  no 
recollection   of  having    ever    conversed  with    him   on   pros- 


RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE    153 

tatectomy  or  any  other  subject,  and  certainly,  if  any  such 
conversation  did  take  place,  it  left  no  impression  on  my 
mind. 

It  is  fortunate,  under  the  circumstances,  that  the  paper 
read  by  Dr.  Guiteras  in  Paris  is  published  in  extenso,  in  the 
New  York  Medical  Journal  of  December  8,  1900,  so  that  we 
are  in  possession  of  his  views  as  to  the  nature  and  scope  of 
Dr.  Fuller's  operation.  After  describing  this  operation  he 
writes  :  '  In  this  way  the  bulk  of  the  prostate  can  often  be 
shelled  out  in  three  large  pieces,  while  at  other  times  it  must 
be  removed  piecemeal.  Enucleation  cannot  always  be  per- 
formed by  this  means,  and  frequently  the  operator  has  to  be 
content  with  the  removal  of  a  piece  forming  the  principal 
part  of  the  barrier.'  This,  then,  would  have  been  the  gist 
of  the  imaginary  '  instruction  '  conveyed  to  me !  I  need 
scarcely  say  that  the  operation  described,  whether  in  its 
technique  or  in  its  scope,  bears  no  resemblance  whatever 
to  that  which  bears  my  name. 

Dr.  Fuller  published  the  description  of  his  operation  with 
six  cases  in  June,  1895,  but  his  teachings  seem  to  have 
fallen  on  deaf  ears.  No  one  even  seems  to  have  thought 
it  worth  while  to  point  out  the  resemblance  it  bore  to 
McGill's  operation,  which  had  then  fallen  into  disfavour. 
So  far  as  I  am  aware,  his  name  was  never  referred  to  on  this 
side  of  the  Atlantic  for  more  than  six  years  after,  till  it  was 
unearthed  from  the  dusty  archives  of  the  Medico-Chirurgical 
Society  by  Mr.  Mayo  Robson  during  the  controversy  that 
ensued  on  the  publication  of  my  tirst  lecture  on  my  operation 
in  July,  1 901,  and  then  only  after  the  attempt  by  Mr.  Robson 
to  father  my  operation  on  himself  had  been  exposed  and 
refuted.  I  am  not  aware  that  in  his  own  country  it  fared 
much  better.  Contrast  with  this  the  profound  interest 
elicited  by  the  publication  of  my  first  four  cases  of  my 
operation;    the    extraordinary    rapidity   with    which    it    has 


i54   RESULTS  OF  TOTAL  ENUCLEATION  OF  PROSTATE 

been  adopted  by  surgeons  all  the  world  over  ;  the  irresistible 
conviction  carried  to  the  profession  and  public  by  the  details 
of  the  several  series,  gradually  increasing  in  number,  since 
published.  Dr.  Fuller's  own  method  of  operating  having 
fallen  flat,  he  now  attempts  to  appropriate  to  himself  what- 
ever merit  attaches  to  my  discovery. 


THE    END 


Bailiicrc,  Tindall  &>  Cox,  8,  Henrietta  Street,  Covent  Garden 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE   BORROWED 

DATE  DUE 

DATE   BORROWED 

DATE   DUE 

\J 

111    9.       if^  n 

14 

UL  o       !bJ42 

i  l3  4 

c 

' 

J 

C2SII  I40IM1OO 

r1 


UL  3      1642 


